Urologic Oncology: Seminars and Original Investigations
Original articlePredictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma
Introduction
Renal cell carcinoma (RCC) is among the most common cancers in both men and women, with an estimated 65,150 new cases and 13,680 deaths for the year 2013 in the United States [1]. The gold standard treatment for clinically localized RCC is surgical excision by radical nephrectomy (RN) or partial nephrectomy (PN) [2].
Although RN and PN are associated with better cancer control relative to other treatment modalities [3], [4], they are associated with a risk of short- and long-term renal injury [5], [6]. Indeed, renal dysfunction is a commonly observed adverse event in patients undergoing RN or PN, with some studies showing up to 60% of patients developing some form of kidney dysfunction after surgery [7], [8]. This is particularly true for older and sicker individuals, who often present with preexisting chronic kidney disease (CKD) at the time of surgery [9]. However, the incidence of acute kidney injury (AKI) and its effect on adverse outcomes in patients with RCC is not yet sufficiently examined. Clinical findings associating AKI episodes with progressive kidney disease mostly derive from cardiac surgery cohorts or critically ill patients [10], [11]. Consequently, effort has to be made to investigate this adverse outcome in the urological surgery setting, with regard to better understanding and identification of AKI determinants. Renal damage following renal surgery can be minimized with appropriate patient and procedure selection, as well as careful operative technique and adequate perioperative resuscitation, as suggested in previous studies [12], [13], [14].
Furthermore, previous investigations on the effect of RN or PN on kidney function reflect care at high-volume tertiary referral centers and may not be generalizable to the US population. On the basis of these considerations, we sought to examine the incidence and predictors of postoperative AKI in a large cohort of patients with RCC treated with RN or PN, who were included in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) [15]. The NSQIP is a prospectively collected database specifically developed to facilitate the assessment of surgical outcomes and complications [16], [17]. Though limited by the lack of data on surgical and imaging characteristics, the NSQIP tracks preoperative serum creatinine (SCr) values and specifically measures postoperative progressive renal dysfunction and acute renal failure (ARF). It is noteworthy that the NSQIP does not provide access to a postoperative SCr value for each patient, but only an indication of whether they experienced AKI.
Section snippets
Data source
The current study relies on the American College of Surgeons NSQIP database. The NSQIP was specifically developed to assess the quality of surgical care, and collects perioperative data on 135 variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity for patients undergoing major surgical procedures in both the inpatient and outpatient setting across the United States. Trained surgical clinical reviewers prospectively collect the
Baseline characteristics
Overall, 1,944 (58.6%) and 1,376 (41.4%) patients treated with RN and PN between 2006 and 2011 were included, respectively. Overall, 1,559 (47.0%) and 1,761 (53.0%) underwent open and minimally invasive surgery, respectively. Table 1 shows the baseline characteristics of the study population. Mean and median age at surgery was 61.4 and 62 years, respectively. Most patients were men (61.3%) and white (88.8%). Overall, 1,107 (33.3%) patients were classified as having no preexisting renal
Discussion
Cho et al. [23] showed in a cohort of Korean RN patients with preoperative normal kidney function that those who experienced AKI postsurgery had a 4.2-fold higher risk of new-onset CKD in the 1-year follow-up. Recent data have suggested that kidney function following renal surgery is correlated with overall survival, regardless of oncological outcomes [7], [24], [25]. Moreover, nephrotoxicity is a side effect of several treatment regimens for advanced RCC, including tyrosine kinase inhibitors.
Conclusion
Overall, 1.8% of patients undergoing surgery for RCC experience postoperative AKI. Surgical technique has a substantial effect on the risk of AKI, as patients treated with RN and with an open approach are at a higher risk of postoperative AKI. The strongest independent predictor of AKI is preexisting CKD stage II or III. Preoperative evaluation of kidney function and identification of predictors for postoperative AKI are important components of preoperative individual risk assessment and
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