Functional and Survival Outcomes of Partial Versus Radical Nephrectomy in Renal Cell Carcinoma Patients With Pre-Existing Chronic Kidney Disease: A Real-World Study

TL;DR

This study compares kidney function and survival outcomes in patients with kidney disease who had partial or radical kidney removal for cancer, finding that partial removal better preserves kidney function.

Contribution

The study introduces a proteinuria-driven risk stratification approach to guide surgical decisions in RCC patients with compromised renal function.

Findings

Partial nephrectomy (PN) preserved kidney function better than radical nephrectomy (RN), with smaller eGFR decline and less CKD progression.

Long-term survival outcomes were comparable between PN and RN groups.

Pre-operative proteinuria was identified as a strong predictor of mortality and a key factor in recommending PN.

Abstract

Managing renal cell carcinoma (RCC) in patients with pre-existing chronic kidney disease (CKD) or a solitary kidney requires balancing oncologic control with maximal renal functional preservation. This study analyzes long-term renal function, survival, and complications between partial nephrectomy (PN) and radical nephrectomy (RN) in this high-risk Vietnamese cohort.

We retrospectively reviewed 90 patients with RCC and reduced pre-operative estimated glomerular filtration rate (eGFR, < 60 mL/min/1.73 m2) or a solitary kidney who underwent surgery at Cho Ray Hospital between 2019 and 2024. Outcomes included changes in eGFR, CKD stage progression, overall survival (OS), cancer-free survival (CFS), and dialysis-free survival (DFS).

Forty-one patients underwent RN and 49 PN. RN cases had significantly larger tumors and higher RENAL complexity scores (P < 0.001). At a mean follow-up of 45.7 months, PN demonstrated a smaller eGFR decline (−13.2 ± 3.5 mL/min/1.73 m2) compared with RN (−23.3 ± 6.0 mL/min/1.73 m2) (P < 0.001), including in the subgroup with eGFR ≤ 45 mL/min/1.73 m2 (P = 0.002). CKD stage progression occurred in 100% of RN versus 62.2% of PN patients. Long-term OS, CFS, and DFS were comparable between groups (all P > 0.05). Age (hazard ratio (HR) 1.1) and positive proteinuria (HR 5.4) were independent predictors of overall mortality.

PN is the preferred strategy for RCC patients with compromised renal function, when technically feasible, due to its superior functional outcomes. We propose a proteinuria-driven risk stratification approach; the presence of pre-operative proteinuria should strongly favor nephron-sparing surgery and necessitate rigorous long-term nephrological co-management to optimize survival.

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