Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
Spectrum Health, Michigan State University School of Medicine, Grand Rapids, Michigan.
J Urol. 2014 Oct;192(4):1057-62. doi: 10.1016/j.juro.2014.04.016. Epub 2014 Apr 18.
Chronic kidney disease is associated with a higher likelihood of progression to end stage renal disease and increased mortality rates. However, the etiology of nephron loss may modify the rate of chronic kidney disease progression and overall survival.
Patients with suspected renal malignancy who had a new baseline glomerular filtration rate of less than 60 ml/minute/1.73 m(2) 6 weeks after surgery were divided into the 2 groups of surgically induced chronic kidney disease (preoperative glomerular filtration rate greater than 60 ml/minute/1.73 m(2)) and preexisting chronic kidney disease due to medical causes followed by surgery. An independent cohort of subjects with chronic kidney disease entirely due to medical causes served as a comparator.
Renal cancer surgery yielded cohorts with surgically induced chronic kidney disease (1,097) and chronic kidney disease due to medical causes followed by surgery (1,053), whereas the group with chronic kidney disease due to medical causes consisted of 42,658 subjects. The patients with chronic kidney disease due to medical causes and chronic kidney disease from medical causes followed by surgery were older compared to those with surgically induced chronic kidney disease, had more medical comorbidities and had a lower baseline glomerular filtration rate (all p <0.001). The group with chronic kidney disease due to medical causes followed by surgery had a lower mean (±SD) new baseline glomerular filtration rate (37±10) compared to the surgically induced chronic kidney disease (48±9) and chronic kidney disease due to medical comorbidities (47±10) groups (p <0.001). The probability of progressive decline in renal function (50% decrease in glomerular filtration rate or need for dialysis) at 3 years was lowest for surgically induced chronic kidney disease, intermediate for chronic kidney disease from medical causes followed by surgery and highest for chronic kidney disease from medical causes when age, gender, race, comorbidities and new baseline glomerular filtration rate were considered (p <0.001). Nonrenal cancer related mortality was substantially lower for those with surgically induced chronic kidney disease compared to the other groups (p <0.001).
Our data suggest that surgically induced chronic kidney disease has a lower rate of functional decline and less impact on survival than chronic kidney disease due to medical causes. These data have potential implications with respect to chronic kidney disease classification and patient counseling for surgical management of various renal disorders including renal cancer.
慢性肾脏病与进展为终末期肾病和死亡率增加的可能性较高相关。然而，肾单位丢失的病因可能会改变慢性肾脏病进展和整体存活率。
术后 6 周肾小球滤过率（GFR）<60ml/min/1.73m²的疑似肾恶性肿瘤患者被分为两组：手术诱导性慢性肾脏病（术前 GFR>60ml/min/1.73m²）和术后因医疗原因引起的慢性肾脏病。一组完全由医疗原因引起的慢性肾脏病患者作为对照组。
肾肿瘤手术后得到了手术诱导性慢性肾脏病组（1097 例）和术后因医疗原因引起的慢性肾脏病组（1053 例），而完全由医疗原因引起的慢性肾脏病组则包含了 42658 例患者。与手术诱导性慢性肾脏病相比，由医疗原因引起的慢性肾脏病和术后由医疗原因引起的慢性肾脏病患者年龄较大，合并症更多，基线肾小球滤过率较低（均 P<0.001）。与手术诱导性慢性肾脏病和由医疗原因引起的慢性肾脏病相比，术后由医疗原因引起的慢性肾脏病组的平均（±SD）新基线肾小球滤过率较低（37±10）（P<0.001）。考虑年龄、性别、种族、合并症和新基线肾小球滤过率后，3 年内肾功能进行性下降（肾小球滤过率下降 50%或需要透析）的概率以手术诱导性慢性肾脏病最低，以术后由医疗原因引起的慢性肾脏病居中，以由医疗原因引起的慢性肾脏病最高（P<0.001）。与其他组相比，手术诱导性慢性肾脏病患者的非肾癌症相关死亡率明显较低（P<0.001）。
我们的数据表明，与由医疗原因引起的慢性肾脏病相比，手术诱导性慢性肾脏病的功能下降速度较慢，对生存的影响较小。这些数据对于慢性肾脏病的分类以及包括肾肿瘤在内的各种肾脏疾病的手术治疗的患者咨询具有潜在意义。
