Contemporary Use of Partial Nephrectomy: Are Older Patients With Impaired Kidney Function Being Left Behind?

Abstract

OBJECTIVES To assess whether patient factors, such as age and preoperative kidney function, were associated with receipt of partial in a national integrated health care system. METHODS We identified patients treated with a radical or partial nephrectomy from 2002-2014 in the Veterans Health Administration. We examined associations among patient age, sex, race/ethnicity, multi-morbidity, baseline kidney function, tumor characteristics and receipt of partial nephrectomy. We estimated the odds of receiving a partial nephrectomy and assessed interactions between covariates and the year of surgery to explore whether patient factors associated with partial nephrectomy changed over time. RESULTS In our cohort of 14,186 patients, 4,508 (31.2%) received a partial nephrectomy. Use of partial nephrectomy increased from 17% in 2002, to 32% in 2008, and to 38% in 2014. Patient race/ethnicity, age, tumor stage, and year of surgery were independently associated with receipt of partial nephrectomy. Black veterans had significantly increased odds of receipt of partial nephrectomy, while older patients had significantly reduced odds. Partial nephrectomy utilization increased for all groups over time, but older patients, and patients with worse baseline kidney function showed the least increase in odds of partial nephrectomy. CONCLUSIONS While the utilization of partial nephrectomy increased for all groups, the greatest increase occurred in the youngest patients and those with the highest baseline kidney function. These trends warrant further investigation to ensure that patients at the highest risk of impaired kidney function are considered for partial nephrectomy whenever possible.

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“…While this could be due to a greater proportion of cases performed as PN in the private sector, as noted by Patel et al ., this trend is in keeping with multiple international studies . Specifically, a significant increase from 17% to 38% was observed between 2002 and 2014 in a Veterans Health cohort, which also described greatest and least uptake in younger and older patients, respectively, much like that observed in this study. Higher proportions have been observed in Europe, including up to 62% in Austria and Germany and 66% in South Korea .…”

“…We identified a progressive increase in the utilization of NSS in Australia over the past 15 years, consistent with smaller state‐based studies . While this could be due to a greater proportion of cases performed as PN in the private sector, as noted by Patel et al ., this trend is in keeping with multiple international studies . Specifically, a significant increase from 17% to 38% was observed between 2002 and 2014 in a Veterans Health cohort, which also described greatest and least uptake in younger and older patients, respectively, much like that observed in this study.…”

“…reported that rates of PN increased from 16% in patients under 45 years and 12% in those above 75 years in 2002, to 66% and 25%, respectively, in 2014. They found that patients who underwent PN were younger, had less comorbidities and better pre‐operative kidney function (less likely to exhibit CKD grade 3) . The more limited uptake in the elderly population is likely due to a combination of decreased expected benefit and concerns about perioperative risk.…”

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“…As the effect of age was only partially mediated by nephrectomy type, this indicates that age associates with CKD through other paths, which is reflective of the general population, where the average annual eGFR reduction for persons aged ≥40 years is 0.75‐1.00 mL/min per 1.73 m 2 . However, we did find that 50% of the association with age was attributable to the type of surgery performed, which invites discussion as to whether PN could be considered more readily for appropriately‐selected older patients …”

“…34 However, we did find that 50% of the association with age was attributable to the type of surgery performed, which invites discussion as to whether PN could be considered more readily for appropriately-selected older patients. 35 The association between CKD development and poorer baseline kidney function is also well known. 36,37 In the present study, preoperative eGFR was the only variable found to have a significant interaction with nephrectomy type, such that even those with AHN ET AL.…”