术前 CKD 阴性患者手术诱导的慢性肾脏病（CKD-S）恶化对肾细胞癌患者生存的影响。

Impact of worsening surgically induced chronic kidney disease (CKD-S) in preoperative CKD-naïve patients on survival in renal cell carcinoma.

机构信息

Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA.

Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan.

出版信息

BJU Int. 2023 Feb;131(2):219-226. doi: 10.1111/bju.15861. Epub 2022 Aug 13.

DOI:10.1111/bju.15861

PMID:35876044

Abstract

OBJECTIVES

To evaluate effects of worsening surgically induced chronic kidney disease (CKD-S) on oncological and non-oncological survival outcomes in renal cell carcinoma (RCC).

PATIENTS AND METHODS

We performed a retrospective analysis of patients who underwent partial (PN) or radical nephrectomy (RN) and were free of preoperative CKD (estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m ). Patients were stratified by CKD stage at last follow-up: no CKD-S (eGFR ≥60 mL/min/1.73 m ), de novo CKD-S 3a (eGFR 45-59 mL/min/1.73 m ), CKD-S 3b (eGFR <45 and ≥30 mL/min/1.73 m ) and CKD-S 4 (eGFR <30 and ≥15 mL/min/1.73 m ). The primary outcome was all-cause mortality (ACM). Secondary outcomes included non-cancer mortality (NCM), cancer-specific mortality (CSM) and de novo CKD-S Stage 3/4. Multivariable analysis (MVA) was utilised to identify risk factors for outcomes. Kaplan-Meier analysis (KMA) was utilised to evaluate overall (OS), non-cancer (NCS), and cancer-specific survival with respect to CKD-S categories.

RESULTS

We analysed 3239 patients. The mean preoperative and last-follow-up eGFRs were 87.4 and 69.5 mL/min/1.73 m , respectively. On last follow-up, 57.9% (n = 1876) had no CKD-S, 18.7% (n = 606) had CKD-S 3a, 15.1% (n = 489) had CKD-S 3b and 8.3% (n = 268) had CKD-S 4. On MVA, de novo CKD-S 3b and 4 were independently associated with ACM (hazard ratios [HRs] 1.3-2.1, P = 0.003-0.001) and NCM (HRs 1.5-2.8, P = 0.021-0.001), but not CSM (P = 0.219-0.909); de novo CKD-S 3a was not predictive for any mortality outcomes (P = 0.102-0.81). RN was independently associated with CKD-S 3-4 (HRs 1.78-1.99, P < 0.001-0.035). Comparing no CKD-S, CKD-S 3a, CKD-S 3b and CKD-S 4, KMA demonstrated worsening outcomes with progressive CKD-S stage: 5-year OS 84% vs 78% vs 71% vs 60% (P < 0.001) and 5-year NCS 93% vs 87% vs 83% vs 72% (P < 0.001).

CONCLUSION

Development of CKD-S Stage 3b and 4, but not 3a, was associated with worsened ACM and NCM. The decision to proceed with nephron preservation via PN should be individualised based on oncological risk and risk of functional decline to CKD-S 3b or 4, and not CKD-S 3a.

摘要

目的

评估手术后慢性肾脏病（CKD-S）恶化对肾细胞癌（RCC）患者肿瘤和非肿瘤生存结局的影响。

方法

我们对接受部分（PN）或根治性肾切除术（RN）且术前无 CKD（估计肾小球滤过率[eGFR]≥60ml/min/1.73m ）的患者进行了回顾性分析。患者按最后一次随访时的 CKD 分期分层：无 CKD-S（eGFR≥60ml/min/1.73m ）、新发 CKD-S3a（eGFR 45-59ml/min/1.73m ）、CKD-S3b（eGFR＜45 且≥30ml/min/1.73m ）和 CKD-S4（eGFR＜30 且≥15ml/min/1.73m ）。主要结局是全因死亡率（ACM）。次要结局包括非癌症死亡率（NCM）、癌症特异性死亡率（CSM）和新发 CKD-S3/4 期。多变量分析（MVA）用于确定结局的危险因素。Kaplan-Meier 分析（KMA）用于评估与 CKD-S 分类相关的总体生存（OS）、非癌症（NCS）和癌症特异性生存。

结果

我们分析了 3239 名患者。术前和最后一次随访的平均 eGFR 分别为 87.4 和 69.5ml/min/1.73m 。最后一次随访时，57.9%（n=1876）无 CKD-S，18.7%（n=606）新发 CKD-S3a，15.1%（n=489）新发 CKD-S3b，8.3%（n=268）新发 CKD-S4。MVA 显示，新发 CKD-S3b 和 4 与 ACM（危险比[HR]1.3-2.1，P=0.003-0.001）和 NCM（HR 1.5-2.8，P=0.021-0.001）独立相关，但与 CSM 无关（P=0.219-0.909）；新发 CKD-S3a 与任何死亡率结局无关（P=0.102-0.81）。RN 与 CKD-S3-4 独立相关（HRs 1.78-1.99，P＜0.001-0.035）。与无 CKD-S 相比，KMA 显示随着 CKD-S 分期的进展，结局恶化：5 年 OS 为 84%、78%、71%和 60%（P＜0.001），5 年 NCS 为 93%、87%、83%和 72%（P＜0.001）。