How is renal insufficiency treated following a partial nephrectomy nephron-sparing surgery (NSS)?

Updated: Apr 01, 2019
  • Author: Reza Ghavamian, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Most cases of renal insufficiency after NSS are the result of transient ischemia during surgery and usually resolve spontaneously. Attention to intraoperative measures to decrease the possibility of this complication, namely hydrating preoperatively, correcting electrolyte abnormalities, using mannitol, maintaining minimum arterial clamp time, and using surface hypothermia, is preventive.

Patients should be aware of the risk of postoperative acute tubular necrosis and the possibility of temporary or permanent dialysis, especially in the setting of a solitary kidney. When recognized postoperatively, appropriate fluid and electrolyte management and use of dialysis (if necessary) can aid in the return of renal function. Stop nephrotoxic medications or alter the dosages. In one series, only 6.5% of patients progressed to end-stage renal disease requiring renal replacement therapy at an average of 8.2 years, of whom 5 had preoperative renal dysfunction. [6]

Lau et al from the Mayo Clinic have addressed the risk of chronic renal failure after partial nephrectomy versus radical nephrectomy with a normal contralateral kidney (unpublished data). This long-term series included 328 patients who were optimally matched for year of surgery, age, sex, renal function, and grade, stage, and size of tumor. The 10-year and 15-year local recurrence-free survival rates were 95% and 99% for partial and radical nephrectomy patients, respectively. Tumor in the contralateral kidney occurred in 1% of the patients in each group. The 10-year and 15-year cause-specific survival rates were 98% and 91%, respectively, for partial nephrectomy and 96% (10 y and 15 y) for radical nephrectomy; thus, no difference in outcome was observed.

More recently, Huang et al (2006) from the Memorial Sloan Kettering cancer center have suggested that radical nephrectomy places the patient in the realm equivalent to that of chronic kidney disease. [7] In this retrospective study, 662 patients with normal renal function and 2 healthy kidneys underwent elective partial or radical nephrectomy for a solitary tumor that was 4 cm or smaller. The glomerular filtration rate (GFR) was estimated using the abbreviated Modification in Diet and Renal Disease Study equation. Twenty-six percent of patients had renal failure prior to the operation.

Postoperatively, the 3-year probability that the patient would be free from a newly onset GFR of lower than 60 mL/min per 1.73 m2 was 80% (95% CI, 73-85) after partial nephrectomy and 35% (28-43; P< 0.001) after radical nephrectomy; corresponding values for a GFR of lower than 45 mL/min per 1.73 m2 were 95% (91-98) and 64% (56-70; P< 0.001), respectively.

Multivariable analysis showed that undergoing radical nephrectomy remained an independent risk factor for a newly onset GFR of lower than 60 mL/min per 1.73 m2 (hazard ratio, 3.82 [95% CI, 2.75-5.32]) and 45 mL/min per 1.73 m2 (11.8 [6.24-22.4]; both P< 0.001). They concluded that undergoing radical nephrectomy is a significant risk factor for the development of chronic kidney disease and may no longer be regarded as the criterion standard treatment for small renal cortical tumors.

Renal replacement therapy (ie, hemodialysis) was required more often in the nephrectomy series than in the NSS group. Furthermore, patients in the radical nephrectomy group had significantly higher serum creatinine levels (P = .003; 1.6 mg% vs 1.3 mg%) than in the nephron-preserving group. This series is particularly credible because of its long-term follow-up (15 y), and it presents compelling evidence that partial nephrectomy is associated with significantly less renal failure than ipsilateral radical nephrectomy in the presence of a contralateral normal kidney.


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