Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Urology, Spectrum Health Medical Group, Michigan State University, Grand Rapids, Michigan.
J Urol. 2018 Feb;199(2):384-392. doi: 10.1016/j.juro.2017.08.096. Epub 2017 Aug 30.
Renal cancer surgery can adversely impact long-term function and survival. We evaluated predictors of chronic kidney disease 5 years and nonrenal cancer mortality 10 years after renal cancer surgery.
We analyzed the records of 4,283 patients who underwent renal cancer surgery from 1997 to 2008. Radical and partial nephrectomy were performed in 46% and 54% of patients, respectively. Cumulative probability ordinal modeling was used to predict chronic kidney disease status 5 years after surgery and multivariable logistic regression was used to predict nonrenal cancer mortality at 10 years. Relevant patient, tumor and functional covariates were incorporated, including the preoperative glomerular filtration rate (A), the new baseline glomerular filtration rate after surgery (B) and the glomerular filtration rate loss related to surgery (C), that is C = A - B. In contrast, partial or radical nephrectomy was not used in the models due to concerns about strong selection bias associated with the choice of procedure.
Multivariable modeling established the preoperative glomerular filtration rate and the glomerular filtration rate loss related to surgery as the most important predictors of the development of chronic kidney disease (Spearman ρ = 0.78). Age, gender and race had secondary roles. Significant predictors of 10-year nonrenal cancer mortality were the preoperative glomerular filtration rate, the new baseline glomerular filtration rate, age, diabetes and heart disease (all p <0.05). Multivariable modeling established age and the preoperative glomerular filtration rate as the most important predictors of 10-year nonrenal cancer mortality (c-index 0.71) while the glomerular filtration rate loss related to surgery only changed absolute mortality estimates 1% to 3%.
Glomerular filtration rate loss related to renal cancer surgery, whether due to partial or radical nephrectomy, influences the risk of chronic kidney disease but it may have less impact on survival. In contrast, age and the preoperative glomerular filtration rate, which reflects general health status, are more robust predictors of nonrenal cancer mortality, at least in patients with good preoperative function or mild chronic kidney disease.
肾癌手术可能会对长期功能和生存产生不利影响。我们评估了肾癌手术后 5 年发生慢性肾脏病 5 期和 10 年非肾癌死亡的预测因素。
我们分析了 1997 年至 2008 年期间接受肾癌手术的 4283 例患者的记录。分别对 46%和 54%的患者进行根治性和部分肾切除术。使用累积概率有序模型预测术后 5 年慢性肾脏病状态，使用多变量逻辑回归预测 10 年非肾癌死亡率。纳入了相关的患者、肿瘤和功能协变量，包括术前肾小球滤过率（A）、术后新的基础肾小球滤过率（B）和与手术相关的肾小球滤过率损失（C），即 C = A - B。然而，由于担心与手术选择相关的强烈选择偏倚，部分或根治性肾切除术并未用于模型中。
多变量模型确定术前肾小球滤过率和与手术相关的肾小球滤过率损失是慢性肾脏病发展的最重要预测因素（Spearman ρ = 0.78）。年龄、性别和种族起次要作用。10 年非肾癌死亡率的显著预测因素是术前肾小球滤过率、新的基础肾小球滤过率、年龄、糖尿病和心脏病（均 p <0.05）。多变量模型确定年龄和术前肾小球滤过率是 10 年非肾癌死亡率的最重要预测因素（c 指数 0.71），而与手术相关的肾小球滤过率损失仅使绝对死亡率估计值变化 1%至 3%。
与肾癌手术相关的肾小球滤过率损失，无论是部分肾切除术还是根治性肾切除术，都会影响慢性肾脏病的风险，但它对生存的影响可能较小。相比之下，年龄和术前肾小球滤过率反映了一般健康状况，是预测非肾癌死亡率的更可靠因素，至少在术前功能良好或轻度慢性肾脏病患者中是这样。
