Patel Hiten D, Pierorazio Phillip M, Johnson Michael H, Sharma Ritu, Iyoha Emmanuel, Allaf Mohamad E, Bass Eric B, Sozio Stephen M
James Buchanan Brady Urological Institute, Department of Urology, and.
Health Policy and Management and.
Clin J Am Soc Nephrol. 2017 Jul 7;12(7):1057-1069. doi: 10.2215/CJN.11941116. Epub 2017 May 8.
Management strategies for localized renal masses suspicious for renal cell carcinoma include radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance. Given favorable survival outcomes across strategies, renal preservation is often of paramount concern. To inform clinical decision making, we performed a systematic review and meta-analysis of studies comparing renal functional outcomes for radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance.
DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1997 to May 1, 2015 to identify comparative studies reporting renal functional outcomes. Meta-analyses were performed for change in eGFR, incidence of CKD, and AKI.
We found 58 articles reporting on relevant renal functional outcomes. Meta-analyses showed that final eGFR fell 10.5 ml/min per 1.73 m lower for radical nephrectomy compared with partial nephrectomy and indicated higher risk of CKD stage 3 or worse (relative risk, 2.56; 95% confidence interval, 1.97 to 3.32) and ESRD for radical nephrectomy compared with partial nephrectomy. Overall risk of AKI was similar for radical nephrectomy and partial nephrectomy, but studies suggested higher risk for radical nephrectomy among T1a tumors (relative risk, 1.37; 95% confidence interval, 1.13 to 1.66). In general, similar findings of worse renal function for radical nephrectomy compared with thermal ablation and active surveillance were observed. No differences in renal functional outcomes were observed for partial nephrectomy versus thermal ablation. The overall rate of ESRD was low among all management strategies (0.4%-2.8%).
Renal functional implications varied across management strategies for localized renal masses, with worse postoperative renal function for patients undergoing radical nephrectomy compared with other strategies and similar outcomes for partial nephrectomy and thermal ablation. Further attention is needed to quantify the changes in renal function associated with active surveillance and nephron-sparing approaches for patients with preexisting CKD.
对于怀疑为肾细胞癌的局限性肾肿块，其管理策略包括根治性肾切除术、部分肾切除术、热消融术和主动监测。鉴于各种策略均有良好的生存结果，肾脏保留通常是首要关注的问题。为指导临床决策，我们对比较根治性肾切除术、部分肾切除术、热消融术和主动监测的肾功能结果的研究进行了系统评价和荟萃分析。
设计、设置、参与者及测量：我们检索了1997年1月1日至2015年5月1日期间的MEDLINE、Embase和Cochrane对照试验中央注册库，以确定报告肾功能结果的比较研究。对估算肾小球滤过率（eGFR）的变化、慢性肾脏病（CKD）的发生率和急性肾损伤（AKI）进行了荟萃分析。
我们发现58篇文章报告了相关的肾功能结果。荟萃分析表明，与部分肾切除术相比，根治性肾切除术患者的最终eGFR每1.73平方米下降10.5毫升/分钟，且根治性肾切除术患者发生3期或更严重CKD（相对风险，2.56；95%置信区间，1.97至3.32）和终末期肾病（ESRD）的风险更高。根治性肾切除术和部分肾切除术的总体AKI风险相似，但研究表明T1a期肿瘤患者接受根治性肾切除术的风险更高（相对风险，1.37；95%置信区间，1.13至1.66）。总体而言，与热消融术和主动监测相比，根治性肾切除术导致肾功能较差的结果相似。部分肾切除术与热消融术的肾功能结果无差异。所有管理策略的ESRD总体发生率较低（0.4%-2.8%）。
局限性肾肿块的不同管理策略对肾功能的影响各异，与其他策略相比，接受根治性肾切除术的患者术后肾功能较差，部分肾切除术和热消融术的结果相似。对于已有CKD的患者，需要进一步关注量化与主动监测和保留肾单位方法相关的肾功能变化。
