Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio.
Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan.
J Urol. 2020 Jul;204(1):42-49. doi: 10.1097/JU.0000000000000797. Epub 2020 Feb 14.
Loss of renal function remains a major limitation of radical nephrectomy. The extent of renal functional compensation by the preserved kidney after radical nephrectomy has not been adequately studied in this elderly population with comorbidities.
A total of 273 patients treated with radical nephrectomy without end stage renal disease with available preoperative nuclear renal scans were included in the analysis. Renal functional compensation was defined as percent change in estimated glomerular filtration rate of the preserved kidney after radical nephrectomy. Estimated glomerular filtration rate was calculated by the Chronic Kidney Disease-Epidemiology Collaboration formula up to 5 years postoperatively. Preoperative/postoperative parenchymal volumes of the preserved kidney were measured from cross-sectional imaging. Multiple regression was used to identify predictive factors for renal functional compensation.
Median age was 67 years and 67% of the patients were male. Overall 70% had hypertension, 26% diabetes and 37% preexisting chronic kidney disease. Locally advanced (T3a or greater) tumors were found in 53% of cases. Renal functional compensation was observed at 2 weeks (median 10%) and increased during the first 3 months (median 26%) after radical nephrectomy. Functional stability was then observed to 5 years. Renal parenchymal volume increased a median of 10% at 3 to 12 months but in addition, the functional efficiency per unit of parenchymal volume also increased 8% (estimated glomerular filtration rate units/cm of parenchyma was 0.236 postoperatively vs 0.208 preoperatively, p=0.004). Age (-0.85, p <0.01), global preoperative estimated glomerular filtration rate (-0.28, p <0.01) and split renal function of the removed kidney (0.61, p <0.01) were independent predictors of renal functional compensation.
Percent renal functional compensation after radical nephrectomy is greater in younger patients, when preoperative estimated glomerular filtration rate is lower and when the removed kidney has more robust function. Increases in measurable parenchymal mass and functional efficiency contribute substantially to renal functional compensation.
肾功能的丧失仍然是根治性肾切除术的主要限制因素。在患有合并症的老年人群中，根治性肾切除术后保留肾脏的肾功能代偿程度尚未得到充分研究。
共纳入 273 例无终末期肾病且术前核肾扫描资料完整的接受根治性肾切除术的患者。将根治性肾切除术后保留肾的肾小球滤过率估计值的百分比变化定义为肾功能代偿。术后 5 年内，通过慢性肾脏病-流行病学合作公式计算肾小球滤过率估计值。从横断影像学上测量保留肾的术前/术后实质体积。采用多元回归分析确定肾功能代偿的预测因素。
中位年龄为 67 岁，67%的患者为男性。总体而言，70%的患者患有高血压，26%的患者患有糖尿病，37%的患者存在慢性肾脏病。53%的病例发现局部晚期（T3a 或更高）肿瘤。在根治性肾切除术后 2 周（中位数 10%）即可观察到肾功能代偿，术后 3 个月内（中位数 26%）代偿增加。随后，在 5 年内观察到功能稳定。术后 3 至 12 个月时，肾实质体积中位数增加 10%，此外，单位肾实质体积的功能效率也增加了 8%（术后肾小球滤过率单位/cm 实质为 0.236，术前为 0.208，p=0.004）。年龄（-0.85，p<0.01）、术前整体肾小球滤过率估计值（-0.28，p<0.01）和切除肾脏的分肾功能（0.61，p<0.01）是肾功能代偿的独立预测因素。
根治性肾切除术后的肾功能代偿百分比在年轻患者、术前肾小球滤过率较低和切除肾脏功能更强的患者中更大。可测量的实质质量和功能效率的增加对肾功能代偿有很大贡献。
