Tumor size and postoperative kidney function following radical nephrectomy
Received 12 December 2018
Accepted for publication 2 March 2019
Published 6 May 2019 Volume 2019:11 Pages 333—348
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Ms Justinn Cochran
Peer reviewer comments 3
Editor who approved publication: Professor Irene Petersen
Robert J Ellis,1–4 Victoria M White,5,6 Damien M Bolton,7,8 Michael D Coory,8 Ian D Davis,9,10 Ross S Francis,2–4 Graham G Giles,5,8 Glenda C Gobe,3,4 Rachel E Neale,1 Simon T Wood,3–4,10 Susan J Jordan1,3
1Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia; 2Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia; 3Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; 4Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, QLD, Australia; 5Cancer Council Victoria, Melbourne, VIC, Australia; 6School of Psychology, Deakin University, Melbourne, VIC, Australia; 7Department of Urology, Austin Health, Melbourne, VIC, Australia; 8Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia; 9Eastern Health Clinical School, Monash University and Eastern Health, Melbourne, VIC, Australia; 10Department of Urology, Princess Alexandra Hospital, Melbourne, VIC, Australia
Background: Chronic kidney disease (CKD) following nephrectomy for kidney tumors is common, and both patient and tumor characteristics may affect postoperative kidney function. Several studies have reported that surgery for large tumors is associated with a lower likelihood of postoperative CKD, but others have reported CKD to be more common before surgery in patients with large tumors.
Objective: The aim of this study was to clarify inconsistencies in the literature regarding the prognostic significance of tumor size for postoperative kidney function.
Study design and setting: We analyzed data from 944 kidney cancer patients managed with radical nephrectomy between January 2012 and December 2013, and 242 living kidney donors who underwent surgery between January 2011 and December 2014 in the Australian states of Queensland and Victoria. Multivariable logistic regression was used to assess the primary outcome of CKD upstaging. Structural equation modeling was used to evaluate causal models, to delineate the influence of patient and tumor characteristics on postoperative kidney function.
Results: We determined that a significant interaction between age and tumor size (P=0.03) led to the observed inverse association between large tumor size and CKD upstaging, and was accentuated by other forms of selection bias. Subgrouping patients by age and tumor size demonstrated that all patients aged ≥65 years were at increased risk of CKD upstaging, regardless of tumor size. Risk of CKD upstaging was comparable between age-matched living donors and kidney cancer patients.
Conclusion: Larger tumors are unlikely to confer a protective effect with respect to postoperative kidney function. The reason for the previously reported inconsistency is likely a combination of the analytical approach and selection bias.
Keywords: renal cell carcinoma, glomerular filtration rate, selection bias, tumor size, kidney cancer, living kidney donors
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