This paper concerns the prevention of chronic kidney disease (CKD) following treatment for renal cell carcinoma (RCC). Over the last 10 years, partial nephrectomy has played an increasing role in the management of RCC, especially T1a disease. It has been shown in large studies to reduce the progression of CKD, based largely on retrospective analysis of outcomes. CKD is present in about a quarter of patients undergoing surgical management of RCC and is associated with both cardiac events and death. The European Organization for Research and Treatment of Cancer (EORTC) randomised trial 30904 did not confirm this finding and actually showed a reduction in overall survival in patients undergoing partial nephrectomy. The paper poses a different, but related question, namely: do those patients who do not have significant renal impairment (CKDIII and above) but are at risk of developing it (hypertension, diabetes), develop poorer renal function following radical nephrectomy compared to partial nephrectomy? Also, what is the relative risk of CKD following partial versus radical nephrectomy? It is a retrospective analysis of 488 patients who were treated consecutively for localised renal cell carcinoma in Melbourne. In those patients, the development of CKD III (GFR less than 60ml/min) was more likely in patients undergoing radical rather than partial nephrectomy. However, partial nephrectomy patients were still at risk if they had risk factors for CKD. The single biggest risk factor was type of surgery for which the overall relative risk was 2.7. This paper confirms the clinical suspicion that normal renal function preoperatively is not a guarantee of preservation of renal function over time. This is particularly so if pre-existent risk factors exist. This paper has a very short follow-up (minimum follow-up was six months), but correlates well with current evidence. In patients identified as being at risk for likely deterioration in renal function over time, partial nephrectomy should be the first choice for management. This is reflected in the current European Association of Urology (EAU) guidelines, and this paper adds further weight to this. 

Patients with medical risk factors for chronic kidney disease are at increased risk of renal impairment despite the use of nephron-sparing surgery.
Satasivam P, Reeves F, Rao K, et al.
Share This
Ciaran Lynch

Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, UK.

View Full Profile