Partial Nephrectomy for Patients with Severe Chronic Kidney Disease: Is It Worthwhile?

Partial nephrectomy (PN) is prioritized over radical nephrectomy (RN) in patients with chronic-kidney-disease (CKD) whenever feasible. However, we hypothesized that some patients with severe-CKD might rapidly progress to end-stage-renal-disease (ESRD), in which case the morbidity that can be associated with PN would not be justified.
A retrospective review of all 62 patients with stage-IV CKD undergoing PN at our institution (1999-2015) was performed. We analyzed preoperative/intraoperative factors and postoperative outcomes. Survival-analyses evaluated factors associated with time-to-progression to ESRD, the primary end-point.
Median age was 67 years, 71% of patients were male, and 84% Caucasian. Comorbidities included hypertension (94%), cardiovascular-disease (53%) and diabetes (32%). Median preoperative-eGFR was 23ml/min/1.73m; and 73% had an open approach. Benign pathology was found in 10 (16%) patients; only 23 (37%) and 7 (11%) patients had tumor grade 3/4 or pT3a disease, respectively. Unfavorable outcomes occurred in 15 patients (24%) defined as either 90 day-mortality (3%), postoperative-complication Clavien≥IIIb(14%), or positive surgical-margin (12%). Median time-to-progression to ESRD was only 27 months (58 months for preoperative-GFR>25ml/min/1.73m versus only 14 months when preoperative-GFR<20ml/min/1.73m). On multivariable-analysis: African-American race [HR:2.55 (1.10-5.95)], preoperative-eGFR 20-25ml/min/1.73m or <20ml/min/1.73m [HR:2.59 (1.16-5.84) and 5.03 (2.03-12.4), respectively] and minimally-invasive approach [HR:2.05 (1.01-4.19)] were independently associated with progression-to-ESRD.
Our data suggest that some patients with stage-IV CKD undergoing PN have substantial comorbidities and non-aggressive pathology, and are at risk for unfavorable perioperative outcomes and rapid-progression to ESRD. Renal-mass biopsy should be strongly considered to improve patient-selection. Alternate strategies (active-surveillance or RN) may be more appropriate, particularly when PN is high-complexity or when the patients is African-American or preoperative-GFR is <25ml/min/1.73m.