The Importance of Nephron- sparing/Focal Therapy: Renal Function - - PowerPoint PPT Presentation

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The Importance of Nephron- sparing/Focal Therapy: Renal Function - - PowerPoint PPT Presentation

Mar 31, 2023 789 likes •977 views

The Importance of Nephron- sparing/Focal Therapy: Renal Function Preservation Jeffrey A. Cadeddu, M.D. Professor of Urology and Radiology UT Southwestern Medical Center Dallas, TX Why is maintaining GFR important? Clinical impact: Increased

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The Importance of Nephron- sparing/Focal Therapy: Renal Function Preservation

Jeffrey A. Cadeddu, M.D. Professor of Urology and Radiology UT Southwestern Medical Center Dallas, TX

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Why is maintaining GFR important?

Weiner et al, 2004 N = 22,634, pooled from 4 community studies (composite includes MI, fatal CHD, nonfatal and fatal stroke, mortality)

Clinical impact: Increased cardiovascular death

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SLIDE 3

Clinical impact: Increase in mortality, morbidity

Go et al NEJM, 2004

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Clinical impact: Complications of CKD

Stevens et al, 2006

N = 10,162: Third national health and nutrition evaluation survey

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Impact of Preserving GFR in Patients with Renal Tumors

  • Huang, Russo et al. J Urol 181:55, 2009

– 2500 RN vs. 500 PN (SEER and Medicare)

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Mortality Risk of Treatment

  • Hollingsworth et al. Cancer 109:1763, 2007

– Competing risk analysis 26,000 pts

  • T1a – 5% risk death w/i 5 years
  • T2 – 27% risk death w/i 5 yrs, despite

surgery

  • > 70 yo, 28% competing-cause mortality,

regardless tumor size

  • Saving kidney function more likely to impact

survival!!!

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SLIDE 7

Renal Preservation: Cryo

  • Bourne et al. J Endourol 2009

– Lap Cryo (n = 77)

  • 14 with CRI – MDRD CrCl = 32
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Renal Fcn after Cryoablation

Series

  • No. Pts.

Mean Tumor size (range) (cm) Mean f/u (mo) Solitary kidneys Preop renal function Postop Renal function

Carvalhal et al 2001 22 2.1 21 No 78.5 ml/min 84.5ml/min Schwartz et al 2006 84 2.6 (1.2-4.7) 10 No 1.18 mg/dL 1.19 mg/dL Finley et al 2008- lap 19 3.0 (1.1-5.4) 13 No 1.2 mg/dL 1.4 mg/dL Finley et al 2008- perc 18 2.7 (1.7-4.7) 11 No 1.2 mg/dL 1.2 mg/dL Munver et al 2008 11 2.6 (1.2-4.3) 43 Yes 1.43 mg/dL 1.57mg/dL Shingleton et al 2003 12 3.1 16 Yes 1.80 mg/dL 1.87 mg/dL

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Renal Fcn after RFA

Series

  • No. Pts.

Mean Tumor size (range) (cm) Mean f/u (mo) Solitary kidneys Preop renal function Postop Renal function

Stern et al 2009 63 2.1 (1.0-4.0) 34 No 76.3 ml/min/1.73m2 74.3 ml/min/1.73m2 Ukimura et al 2004 8 3.8 (20-53) 17 No Mean change -0.05 mg/dL Hoffmann et al 2009 10 2.7 (1.9-4.2) 3-24 Yes 79 ml/min 71 ml/min

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Renal Function Impact of Ablation in Solitary Kidney

  • Raman et al. Can J Urol, 2009.
  • No. pts

16

  • No. tumors

21 Gender (male/female) 12/4 Age, yrs (range) 66.1 (52.3-81.4) Radiographic tumor size, cm (range) 2.6 (1.1-4.0) Tumor location1 (%) Exophytic Mesophytic Endophytic 10 (48) 4 (19) 7 (33) Approach (%) Percutaneous Laparoscopic 12 (75) 4 (25) Length of stay (days) Mean (range) 0.75 (0-3) Pre-ablation pathology (%) Renal cell carcinoma Oncocytoma Non-diagnostic No biopsy 16 (76) 2 (10) 2 (10) 1 (5) Follow-up (mos) Mean Range 30.7 1.5 – 66.0 GFR (mL/min/1.73m2) Pre-op Mean Range Last F/U Mean Range % change from baseline 53.5 22.7 – 89.9 47.2 16.0 – 76.7 11.8

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Renal Preservation: T1a Tumors Treated by Ablation or Resection

(Lucas, Raj et al, J Urol 179:75, 2008)

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RENAL PRESERVATION: Outcomes for T1a Tumors Treated by Ablation

  • r Resection

(Lucas et al, J Urol 179:75, 2008)

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Renal Function Impact of RFA vs. PN in Solitary Kidney

  • Raman, Matin, Leveillee et al. BJUI 2010

RFA (n=33) OPN (n=31) p value CT tumor size (cm) Median (range) 2.9 (2.0 - 4.0) 3.2 (2.0 – 4.0) 0.02†

  • No. endophytic tumors 1 (%)

11 (33) 12 (39) 0.65 Median % GFR change (IQR) Last follow-up 0-3 Months follow-up 12 Months follow-up

  • 12.9 (18)
  • 6.9 (14)
  • 11.2 (15)
  • 26.3 (31)
  • 14.1 (22)
  • 22.4 (27)

0.003† 0.01† 0.003† Dialysis dependent < 3mos from intervention 0/33 (0%) 1/31 (3.2%) 0.30

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Clinical, Pathologic and Functional Outcomes after Nephron-Sparing Surgery in Patients with a Solitary Kidney: A Multi-center Experience Mues, et al. (in submission)

  • Columbia University
  • University of Florida
  • UT Southwestern
  • UC Irvine
  • AMC, Amsterdam
  • Long Island Jewish NY
  • Hackensack University

Medical Center

  • University of Wisconsin
  • Duke University
  • University of Chicago
  • Ochsner Clinic
  • University of Michigan
  • OPN (50)
  • LPN (50)
  • Lap Cryo (50)
  • Perc Cryo (28)
  • Lap RFA (11)
  • Perc RFA (16)
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Variable Ablation Partial Nephrectomy p value # patients 98 100 # procedures 105 100 ─ Mean age (years) 64 64 0.85 Mean BMI 29 29 0.93 Mean tumor size (cm) 2.5 3.9 <0.001 Mean pre-op creatinine (mg/dL) 1.4 1.4 0.65

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Time Ablation Estimated GFR* (mL/min/1.73m2) Partial Nephrectomy Estimated GFR* (mL/min/1.73m2) p value Pre-operative 59 59 0.91 3 months 52 53 0.76 12 months 51 52 0.78

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Renal Function Preservation is Important

  • Standard surgical treatments increase risk of developing

CKD

  • Focal therapy (RFA or Cryo) may have smallest impact on

long term renal function