Smaller decline of renal function after nephroureterectomy predicts poorer prognosis of upper tract urothelial carcinoma: a multicentre retrospective study

Abstract

Purpose Renal function is frequently impaired in the patients with upper tract urothelial carcinoma. We aimed to evaluate the impact of renal function and its change after surgery on survival rates in patients with upper tract urothelial carcinoma after nephroureterectomy. Methods The study cohort comprised 755 patients with upper tract urothelial carcinoma who underwent nephroureterectomy between 1995 and 2016 at nine hospitals in Japan. Estimated glomerular filtration rate was calculated using the three-variable Japanese equation for glomerular filtration rate estimation from serum creatinine level and age. Outcomes were recurrence-free, cancer-specific and overall survivals. Univariate and multivariate Cox proportional hazards regression analyses were used. Results Median patients’ age was 72 years old. Pre- and post-surgical median estimated glomerular filtration rate were 55.5 and 42.9 ml/min/1.73 m2, respectively. Median estimated glomerular filtration rate decline after surgery, which represents function of the affected side kidney, was 13.1 ml/min/1.73 m2. The 5-year recurrence-free, cancer-specific and overall survivals were 68.3, 79.4 and 74.0%, respectively. Multivariate analysis indicated that lower preoperative estimated glomerular filtration rate and estimated glomerular filtration rate decline were associated with poorer recurrence-free, cancer-specific and overall survivals, but post-operative estimated glomerular filtration rate was not. Estimated glomerular filtration rate decline was more significant poor-prognosticator than preoperative estimated glomerular filtration rate. Proportions of the patients with estimated glomerular filtration rate <60 ml/min/1.73 m2 before surgery were 50.6 and 73.2% in organ-confined disease and locally advanced disease, respectively (P < 0.0001). After surgery, they were 91.6 and 89.8%, respectively (P = 0.3896). Conclusions Lower preoperative renal function, especially of the affected side kidney, was significantly associated with poor prognosis after nephroureterectomy for upper tract urothelial carcinoma. Many patients with locally advanced disease have reduced renal function at diagnosis and even more after surgery.

Impact of nephroureterectomy on postoperative renal function in upper tract urothelial carcinoma: A multicenter retrospective study

“…Because RNU results in the loss of a unilateral kidney, impaired renal function is prevalent in patients with UTUC. Using a eGFR cutoff of <60 mL/min/1.73 m 2 (CKD stage ≥3), the rate of patients with postoperative eGFR ≥60 mL/min/1.73 m 2 was 9.0%, which was similar to that reported in previous studies from Japan (9.1%–11.3%), 2,18 but lower than in Western countries (range, 16%–22%, Figure 5). 4–6 The median decline in eGFR after surgery was 25.1%, which was slightly higher reported in previous studies (range, 13.1%–24%) 2,4–6 .…”

“…Because kidney size is related to a number of glomeruli, body size is a key factor in renal function 19 . The median body mass index in Japanese patients is 22.7 kg/m 2 (IQR: 20.8–24.6 kg/m 2 ) compared with 28.2 kg/m 2 (IQR: 24–32 kg/m 2 ) in Western countries 2,4 . The difference in the prevalence of preoperative hydronephrosis and CKD stage ≥3 compared with Western studies 2,4–6 .…”

“…Moreover, a poor survival outcome is the primary issue among patients with locally invasive UTUC (pT2–4 or N+) and those have indicated the necessity of perioperative chemotherapy to improve disease control. However, the major problem experienced by patients is impaired renal function owing to radical nephroureterectomy (RNU), which is the gold standard treatment 2–7 . Platinum‐based adjuvant chemotherapy is one of the standard therapies for locally advanced UTUC, but not all patients are candidates for cisplatin‐based regimens because of older age, comorbidities, and impaired renal function, especially in the adjuvant setting 8–10 .…”

Changes in renal function after nephroureterectomy for upper urinary tract carcinoma: analysis of a large multicenter cohort (Radical Nephroureterectomy Outcomes (RaNeO) Research Consortium)

“…After RNU for UTUC, patients may require adjuvant chemotherapy for advanced stage or disease progression. Only 50% of patients are still eligible for platinum-based protocols, due postoperative renal function failure [ 8 – 10 ] which effects oncological outcomes as recently demonstrated [ 5 ]. Early identification of patients at high risk of eGFR reduction after extirpative surgery, for whom adjuvant therapy is no longer feasible, may be addressed by neoadjuvant regimens, resulting in an increase in survival [ 11 ].…”

“…UTUC patients have an increased risk of chronic kidney disease(CKD) because of age, comorbidities, smoking exposure, and potential impairment of contralateral kidney due to diagnostic procedures or contralateral UTUC [ 4 ]. Previous studies showed that CKD may lead to worse overall and cancer-specific survival after treatment for renal cell carcinoma (RCC) as well as UTUC [ 5 , 6 ]. Despite the benefit of adjuvant chemotherapy in prolonging survival [ 7 ] and reducing the risk of disease recurrence in locally advanced UTUC [ 8 ], 50% of patients are not eligible for platinum-based protocols due to postoperative renal failure [ 9 , 10 ].…”