Nefrectomia parziale vs radicale nel contesto delle grandi masse renali: preservazione della funzionalità renale a breve e lungo termine

Abstract

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Background: Renal function deterioration following kidney surgery is associated with increased all-cause mortality. In patients with renal masses >4 cm, whether partial vs radical nephrectomy (PN vs RN) might affect long-term functional outcomes is unknown. Objective: To test the association between type of surgery (PN vs RN) and: a). post-operative acute kidney injury (AKI); b). recovery of ≥90% preoperative eGFR one year after surgery; c) upstaging ≥1 CKD stage at one year as compared to preoperative stage; d) eGFR decline ≤45 ml/min/1.73 m2 one-year after surgery. Methods: A collaborative database including patients’ data from 23 high-volume institutions was exploited. Only surgically-treated patients with single, unilateral, clinical T1b-2 renal masses with no evidence of systemic disease were included. Multivariable logistic regression analyses were performed; clinical stage-specific sensitivity analyses (cT1b and cT2) were performed. Results: 968 vs 325 patients treated with PN vs RN were identified. The rate of AKI was lower in PN vs RN patients (17% vs 58%, p<0.001). One year after surgery, in PN vs RN patients respectively, the rate of recovery of ≥90% of baseline eGFR was 51% vs 16%, the rate of CKD progression of ≥1 stage was 38% vs 65%, and the rate of eGFR decline ≤45 ml/min/1.73 m2 was 10% vs 23% (all p<0.001). RN reached the independent unfavorable predictor status of all the outcomes of interest: a). AKI, odds ratio (OR): 7.61; b). one-year ≥90% eGFR recovery, OR: 0.30; c). one-year CKD upstaging, OR: 1.78; d). one-year eGFR decline ≤45 ml/min/1.73 m2, OR: 2.36 (all p-values ≤0.002). Conclusions: In patients with cT1b-2 renal masses, RN might portend worse worse immediate, as well as one-year functional outcomes. When technically feasible, efforts should be made to preserve the kidney in case of large renal renal masses as this might restrain the likelihood of metabolic and cardiovascular sequele associated to glomerular function loss.