Renal Functional Outcomes after Surgery, Ablation, and Active Surveillance of Localized Renal Tumors: A Systematic Review and Meta-Analysis

Abstract

Background and objectives: Management strategies for localized renal masses suspicious for renal cell carcinoma include radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance. Given favorable survival outcomes across strategies, renal preservation is often of paramount concern. To inform clinical decision making, we performed a systematic review and meta-analysis of studies comparing renal functional outcomes for radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance.

Design, settings, participants, & measurements: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1997 to May 1, 2015 to identify comparative studies reporting renal functional outcomes. Meta-analyses were performed for change in eGFR, incidence of CKD, and AKI.

Results: We found 58 articles reporting on relevant renal functional outcomes. Meta-analyses showed that final eGFR fell 10.5 ml/min per 1.73 m2 lower for radical nephrectomy compared with partial nephrectomy and indicated higher risk of CKD stage 3 or worse (relative risk, 2.56; 95% confidence interval, 1.97 to 3.32) and ESRD for radical nephrectomy compared with partial nephrectomy. Overall risk of AKI was similar for radical nephrectomy and partial nephrectomy, but studies suggested higher risk for radical nephrectomy among T1a tumors (relative risk, 1.37; 95% confidence interval, 1.13 to 1.66). In general, similar findings of worse renal function for radical nephrectomy compared with thermal ablation and active surveillance were observed. No differences in renal functional outcomes were observed for partial nephrectomy versus thermal ablation. The overall rate of ESRD was low among all management strategies (0.4%-2.8%).

Conclusions: Renal functional implications varied across management strategies for localized renal masses, with worse postoperative renal function for patients undergoing radical nephrectomy compared with other strategies and similar outcomes for partial nephrectomy and thermal ablation. Further attention is needed to quantify the changes in renal function associated with active surveillance and nephron-sparing approaches for patients with preexisting CKD.

Keywords: Acute Kidney Injury; Attention; Carcinoma, Renal Cell; Clinical Decision-Making; Confidence Intervals; Humans; Incidence; Kidney Failure, Chronic; MEDLINE; Nephrectomy; Nephrons; Renal Insufficiency, Chronic; Risk; acute kidney injury; chronic kidney disease; glomerular filtration rate; kidney; kidney neoplasms; outcome studies.

Copyright © 2017 by the American Society of Nephrology.

Figures

Figure 1.

Summary of literature search showing the included 58 unique articles. AHRQ, Agency for Health Research and Quality.

Figure 2.

Mean change in eGFR shown to favor partial nephrectomy (PN) and thermal ablation (TA) over radical nephrectomy (RN) on meta-analysis. The comparisons shown are (A) RN versus PN, (B) RN versus TA, and (C) PN versus TA. The widths of the horizontal lines represent the 95% confidence intervals (95% CIs) for each study. The diamonds at the bottoms of the graphs indicate the 95% CIs. WMD, weighted mean difference.

Figure 3.

Incidence of stage 3 CKD shown to favor partial nephrectomy (PN) and thermal ablation (TA) over radical nephrectomy (RN) on meta-analysis. The comparisons shown are (A) RN versus PN, (B) RN versus TA, and (C) PN versus TA. The widths of the horizontal lines represent the 95% confidence intervals (95% CIs) for each study. The diamonds at the bottoms of the graphs indicate the 95% CIs. RR, risk ratio.

Figure 4.

Acute kidney injury shown to favor partial nephrectomy (PN) over radical nephrectomy (RN) for T1a tumors on meta-analysis but with no difference for PN, RN, and thermal ablation (TA) when comparing all included tumors. The comparisons shown are (A) RN versus PN overall, (B) RN versus PN for T1a tumors, (C) RN versus TA, and (D) PN versus TA. The widths of the horizontal lines represent the 95% confidence intervals (95% CIs) for each study. The diamonds at the bottoms of the graphs indicate the 95% CIs. RR, risk ratio. *Correction factors were applied.

Figure 4.

Acute kidney injury shown to favor partial nephrectomy (PN) over radical nephrectomy (RN) for T1a tumors on meta-analysis but with no difference for PN, RN, and thermal ablation (TA) when comparing all included tumors. The comparisons shown are (A) RN versus PN overall, (B) RN versus PN for T1a tumors, (C) RN versus TA, and (D) PN versus TA. The widths of the horizontal lines represent the 95% confidence intervals (95% CIs) for each study. The diamonds at the bottoms of the graphs indicate the 95% CIs. RR, risk ratio. *Correction factors were applied.