Predictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma

doi:10.1016/j.urolonc.2014.05.002

Urologic Oncology: Seminars and Original Investigations

Volume 32, Issue 8, November 2014, Pages 1259-1266

https://doi.org/10.1016/j.urolonc.2014.05.002 Get rights and content

Abstract

Introduction

Patients with renal cell carcinoma who were treated with radical nephrectomy (RN) or partial nephrectomy (PN) are at risk of postoperative acute kidney injury (AKI), and in consequence, short- and long-term adverse outcomes. We sought to identify independent predictors of 30-day AKI in patients undergoing RN or PN.

Materials and methods

Between 2005 and 2011, patients who underwent RN or PN for renal cell carcinoma within the National Surgical Quality Improvement Program data set were identified. Patients with preexisting severe renal failure, defined as a preoperative estimated glomerular filtration rate<30 ml/min/1.73 m², were excluded from the analyses. AKI was defined as an elevation of serum creatinine>2 mg/dl above baseline or the need for dialysis within 30 days of surgery. Univariable and multivariable logistic regression analyses were used to examine the association between preoperative factors and the risk of postoperative AKI.

Results

Overall, 1,944 (58.6%) and 1,376 (41.4%) patients underwent RN and PN, respectively. Overall, 1.8% of the patients included in the study experienced AKI within an average of 5.4 days after RN or PN. Independent predictors for AKI included obesity (odds ratio [OR] = 2.24, P = 0.04), history of neurovascular disease (OR = 5.29, P<0.001), and a preoperative chronic kidney disease stage II (OR = 10.00, P = 0.03) or stage III (OR = 26.49, P = 0.02). Furthermore, RN (OR = 2.87, P = 0.02) or the open approach (OR = 2.18, P = 0.04) was significantly associated with postoperative AKI. AKI was significantly associated with adverse postoperative outcomes, such as prolonged length of stay, occurrence of any complication, and mortality (all P <0.001).

Conclusions

The assessment of preoperative kidney function and comorbidity status is essential to identify patients at risk of postoperative AKI. In addition to preoperative chronic kidney disease stages II and III, neurovascular disease, obesity, and surgical approach (RN or open) represent predictors of 30-day AKI. Careful patient selection as well as preoperative planning may help reduce this unfavorable postoperative outcome.

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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We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS).
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Over the past 2 decades, significant research and advancements have been made in oncology and its therapeutics. Thanks to novel diagnostic methods, treatments, and supportive measures, patients with cancer live longer and have a better quality of life. However, an unforeseen consequence of this progress has been increasing medical complications, including acute kidney injury. The purpose of this review is to provide an overview of the epidemiology and most common causes of acute kidney injury in patients with cancer unrelated to oncological treatment.
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The reduction of renal mass after radical nephrectomy (RN) for renal neoplasm, could be associated with compensatory hypertrophy of the contralateral kidney. The capacity of compensation will determine the renal function (RF) evolution. Measuring of total renal volume (TRV) of the remaining kidney pre and post RN can help assess the RF evolution.
To determine the correlation between TRV pre and post nephrectomy (a year of follow-up) with RF.
A retrospective cohort study was carried out in 47 patients who had undergone RN from 2014 to 2018, due to renal cell carcinoma (confirmed by histopathology).
The TRV was calculated, pre and post (a year of follow-up) RN, using ellipsoid formula equation, which were compared with clinical and analytical data. The results were analyzed by multivariate linear logistic models.
The median age at the time of RN was 70 years old (range, 40–88 years). Most of them were men, 66%. The estimated glomerular filtration rate (eGFR) pre and post nephrectomy was 78 (40–100) and 53.3 ml/min/m² (30–90) respectively (p = 0.01). The TRV pre and post-nephrectomy was 168.2 ml (100.4–257.2) and 187.8 ml (115.5–273.1) respectively (p = 0.001).
The pre-nephrectomy eGFR (β = 0.62; p = 0.034) and the TRV (β = 1.08; p < 0.0001) were positively correlated with the post-nephrectomy TRV, while the eGFR at year of follow-up was correlated negatively (β = −1.18; p = 0.047).
The measurement of pre and post nephrectomy TRV can help to predict renal function evolution at a year of follow-up.
La reducción de la masa renal tras la nefrectomía radical en pacientes con neoplasias renales puede producir la hipertrofia compensadora del riñón contralateral. La capacidad de compensación determinará la evolución de la función renal. La medición del volumen renal total (VRT) del riñón remanente antes y después de la nefrectomía puede ayudar a evaluar la evolución de la función renal.
Determinar la correlación entre el VRT pre y posnefrectomía con la función renal al año de seguimiento.
Estudio retrospectivo de observación en 47 pacientes adultos con neoplasias renales que fueron sometidos a nefrectomía radical. El VRT pre y posnefrectomía (al año de seguimiento) fue calculado mediante la ecuación de la elipsoide (TAC y/o RNM), que fueron comparados con datos clínicos y analíticos. Los resultados fueron analizados mediante regresión lineal uni y multivariante.
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El FGe prenefrectomía (β = 0,62; p = 0,034) y el VRT pre (β = 1,08; p < 0,0001) se correlacionaron positivamente con el VRT posnefrectomía. Sin embargo, el FGe al año se correlacionó negativamente (β = –1,18; p = 0,047).
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Original articlePredictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma

Abstract

Introduction

Materials and methods

Results

Conclusions

Introduction

Section snippets

Data source

Baseline characteristics

Discussion

Conclusion

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Original article
Predictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma