Division of Urology, Spectrum Health, Michigan State University, Grand Rapids, Michigan, USA.
J Urol. 2013 May;189(5):1649-55. doi: 10.1016/j.juro.2012.11.121. Epub 2012 Nov 28.
Chronic kidney disease from medical causes is present in 25% to 30% of patients before surgery for renal cancer. Although chronic kidney disease due to medical causes is typically associated with a 2% to 5% annual renal functional decline and decreased overall survival, reduced glomerular filtration rate occurring only after surgery may not have the same negative consequences.
All patients undergoing surgery for suspected renal malignancy were identified in an institutional registry. Median clinical followup was 6.6 years.
Of 4,180 patients 28% had a preoperative glomerular filtration rate of less than 60 ml/minute/1.73 m(2) (chronic kidney disease due to medical causes) and in 22% the glomerular filtration rate decreased to less than 60 ml/minute/1.73 m(2) only after surgery (surgically induced chronic kidney disease). Preoperative glomerular filtration rate was a strong predictor of overall survival on univariable and multivariable analysis. The risk of death after renal surgery was 1.8, 3.5 and 4.4-fold higher in patients with preoperative chronic kidney disease stages 3, 4 and 5, respectively, vs normal preoperative glomerular filtration rate. Average overall loss of renal function was 23%, including 13% within 90 days after surgery and 3.5% annually thereafter. Postoperative glomerular filtration rate only predicted survival for patients with preexisting chronic kidney disease due to medical causes. Neither surgically induced chronic kidney disease nor postoperative glomerular filtration rate was a significant predictor of survival in patients without preexisting chronic kidney disease due to medical causes. Annual renal functional decline was 4.7% and 0.7% for patients with chronic kidney disease due to medical causes and surgically induced chronic kidney disease, respectively, with a greater than 50% reduction in glomerular filtration rate in 7.3% and 2.2%, respectively (p <0.0001). Annual renal functional decline greater than 4.0% was associated with a 43% increase in mortality (p <0.0001).
Surgically induced chronic kidney disease is associated with a relatively low risk of progressive renal functional decline and impact on survival does not appear to be substantial during intermediate term followup. In contrast, preoperative chronic kidney disease due to medical causes places patients at increased risk, indicating nephron sparing surgery for such patients.
在接受肾肿瘤手术的患者中，有 25%至 30%的患者存在由医学原因引起的慢性肾脏病。虽然由医学原因引起的慢性肾脏病通常与每年 2%至 5%的肾功能下降和总体生存率降低有关，但仅在手术后发生的肾小球滤过率降低可能不会产生相同的负面后果。
在机构注册中心确定了所有接受疑似肾恶性肿瘤手术的患者。中位临床随访时间为 6.6 年。
在 4180 名患者中，28%的患者术前肾小球滤过率低于 60ml/min/1.73m2（由医学原因引起的慢性肾脏病），22%的患者仅在手术后肾小球滤过率降至 60ml/min/1.73m2以下（手术引起的慢性肾脏病）。术前肾小球滤过率是单变量和多变量分析中总体生存率的强有力预测因素。与术前肾小球滤过率正常的患者相比，术前慢性肾脏病 3 期、4 期和 5 期患者的肾手术后死亡风险分别高出 1.8 倍、3.5 倍和 4.4 倍。平均整体肾功能丧失 23%，其中 90 天内丧失 13%，此后每年丧失 3.5%。术后肾小球滤过率仅预测有术前由医学原因引起的慢性肾脏病患者的生存。对于没有术前由医学原因引起的慢性肾脏病的患者，手术引起的慢性肾脏病或术后肾小球滤过率均不是生存的显著预测因素。由医学原因引起的慢性肾脏病患者的年肾功能下降率为 4.7%，手术引起的慢性肾脏病患者为 0.7%，肾小球滤过率分别下降超过 50%的患者比例为 7.3%和 2.2%（p<0.0001）。肾小球滤过率每年下降超过 4.0%与死亡率增加 43%相关（p<0.0001）。
手术引起的慢性肾脏病与相对较低的进行性肾功能下降风险相关，并且在中期随访期间对生存的影响似乎并不显著。相比之下，由医学原因引起的术前慢性肾脏病使患者处于更高的风险之中，表明此类患者应进行保肾手术。
