肾癌患者单侧根治性肾切除术后肾功能的变化
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摘要
目的:观察肾癌患者行单侧根治性肾切除术后肾功能的变化,探讨术后急性肾损伤(AKI)及远期慢性肾脏病(CKD)风险的危险因素。方法:回顾性分析2013年1月至2018年1月于上海交通大学医学院附属瑞金医院泌尿外科行单侧根治性肾切除术的85例肾癌患者的临床资料,观察围手术期及远期肾功能变化,评估围手术期AKI发生率及危险因素;采用Kaplan-Meier生存曲线分析术后远期CKD的发生率,通过对临床资料进行单因素比较及多因素Logistic回归分析,探讨根治性肾癌术后发生CKD的独立危险因素。结果:85例患者中位随访时间18(7～26)月,术后估算的肾小球滤过率(eGFR)变化趋势分为术后快速下降、3月内逐步恢复、后期相对稳定三个阶段。47例(55.3%)患者术后发生AKI,其中26例(55.3%)出院时肾功能恢复,术前eGFR较低者恢复比例低(P=0.028)。单因素分析提示男性、糖尿病、高尿酸血症、健侧GFR及肿瘤大小与AKI发生有关,多元Logistic回归分析提示健侧GFR水平低下(OR=0.892,P=0.018)与合并糖尿病(OR=7.856,P=0.038)是导致术后AKI的独立危险因素。术前eGFR≥60 ml/(min·1.73m~2)的78例患者中36例(46.1%)随访进展为CKD,Kaplan-Meier生存曲线估计1年、3年及5年累计CKD发生率分别为38.9%、50.8%及57.0%。单因素分析提示年龄、健侧GFR、术前及术后eGFR与远期CKD发生有关,多元Logistic回归分析提示术前eGFR低(OR=0.794,P=0.005)是导致根治性肾切除术后进展为CKD的独立危险因素。结论:根治性肾切除术后AKI与远期CKD发病率均较高,健侧GFR低下、基础糖尿病与术后AKI发生密切相关,术前eGFR偏低是远期CKD进展的独立危险因素。
Objective:To study the change of renal function in renal cell carcinoma(RCC) patients who underwent radical nephrectomy,to explore the risk factors of acute kidney injury(AKI) after operation and chronic kidney disease(CKD) in long-term followe-up. Methodology:data of 85 RCC patients having radical nephrectomy in Shanghai Ruijin North Hospital from Jan-2013 to Jan-2018 was collected and retrospectively studied.Incidence of AKI after operation was calculated and its risk factors were analyzed.Kaplan-Meier method was used to estimate the cumulative incidence of CKD during the follow-up.Univariate and multivariate analysis were performed to find out risk factors for CKD. Results:Eighty-five patients with a median follow-up of 18(7-26) months,were enrolled in this study.A rapid decline of eGFR was observed immediately after operation.Then eGFR gradually recoverd for the next 3 months and remained relatively stable during the follow-up.There were 47 cases(55.3%) of AKI,26 of which(55.3%) recovered before discharge.A low preoperative eGFR indicated a prolonged recovery(P=0.028).Univariate analysis indicated that male gender,diabetes,hyperuricemia,contralateral kidney with lower eGFR and smaller tumor size were associated with AKI.Logistics regression analysis showed that contralateral kidney with lower eGFR(OR=0.892,P=0.018) and diabetes(OR=7.856,P=0.038) were independent risk factors for AKI.36 out of 78 patients with normal preoperative renal function progressed to CKD during the follow-up.The 1,3 and 5 year cumulative incidence of CKD estimated by Kaplan-Meier method was 38.9%,50.8% and 57.0%,respectively.There were significant differences in age,eGFR of the contralateral kidney,pre-and post-operative eGFR between the CKD and non-CKD groups.Logistics regression analysis showed that lower preoperative eGFR(OR=0.794,P=0.005) was an independent risk factor for CKD. Conclusion:patients with RCC have a high incidence of AKI and CKD after radical nephrectomy.Contralateral kidney with lower eGFR and diabetes were associated with AKI,while lower preoperative eGFR was associated with CKD in the long term.
Objective:To study the change of renal function in renal cell carcinoma(RCC) patients who underwent radical nephrectomy,to explore the risk factors of acute kidney injury(AKI) after operation and chronic kidney disease(CKD) in long-term followe-up. Methodology:data of 85 RCC patients having radical nephrectomy in Shanghai Ruijin North Hospital from Jan-2013 to Jan-2018 was collected and retrospectively studied.Incidence of AKI after operation was calculated and its risk factors were analyzed.Kaplan-Meier method was used to estimate the cumulative incidence of CKD during the follow-up.Univariate and multivariate analysis were performed to find out risk factors for CKD. Results:Eighty-five patients with a median follow-up of 18(7-26) months,were enrolled in this study.A rapid decline of eGFR was observed immediately after operation.Then eGFR gradually recoverd for the next 3 months and remained relatively stable during the follow-up.There were 47 cases(55.3%) of AKI,26 of which(55.3%) recovered before discharge.A low preoperative eGFR indicated a prolonged recovery(P=0.028).Univariate analysis indicated that male gender,diabetes,hyperuricemia,contralateral kidney with lower eGFR and smaller tumor size were associated with AKI.Logistics regression analysis showed that contralateral kidney with lower eGFR(OR=0.892,P=0.018) and diabetes(OR=7.856,P=0.038) were independent risk factors for AKI.36 out of 78 patients with normal preoperative renal function progressed to CKD during the follow-up.The 1,3 and 5 year cumulative incidence of CKD estimated by Kaplan-Meier method was 38.9%,50.8% and 57.0%,respectively.There were significant differences in age,eGFR of the contralateral kidney,pre-and post-operative eGFR between the CKD and non-CKD groups.Logistics regression analysis showed that lower preoperative eGFR(OR=0.794,P=0.005) was an independent risk factor for CKD. Conclusion:patients with RCC have a high incidence of AKI and CKD after radical nephrectomy.Contralateral kidney with lower eGFR and diabetes were associated with AKI,while lower preoperative eGFR was associated with CKD in the long term.
引文
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2 Kellum JA,Lameire N; KDIGO AKI Guideline Work Group.Diagnosis,evaluation,and management of acute kidney injury:a KDIGO summary.Crit Care,2013 Feb 4,17(1):204.
3 Chawla LS,Bellomo R,Bihorac A,et al.Acute kidney disease and renal recovery:consensus report of the Acute Disease Quality Initiative(ADQI) 16 Workgroup.Nat Rev Nephrol,2017,13(4):241-257.
4 National Kidney Foundation.K/DOQI clinical practice guidelines for chronic kidney disease:evaluation,classification,and stratification.Am J Kidney Dis,2002,39(2 Suppl 1):S1-266.
5 Kopple JD.National kidney foundation K/DOQI clinical practice guidelines for nutrition in chronic renal failure.Am J Kidney Dis,2001,37(1 Suppl 2):S66-70.
6 Hiten DP,Phillip MP,Michael HJ,et al.Renal functional outcomes after surgery,ablation,and active surveillance of localized renal tumors:a systematic review and meta-analysis.Clin J Am Soc Nephrol,2017(12):1057-1069.
7 Shirley DG,Walter SJ.Acute and chronic changes in renal function following unilateral nephrectomy.Kidney Int,1991,40(1):62-68.
8 Chamberlain RM,Shirley DG.Time course of the renal functional response to partial nephrectomy:measurements in consciousrats.Exp Physiol,2007,92(1):251-262.
9 Shin S,Han Y,Park H,et al.Risk factors for acute kidney injury after radical nephrectomy and inferior vena cava thrombectomy for renal cell carcinoma.J Vasc Surg,2013,58(4):1021-1027.
10 Schmid M,Abd-El-Barr AE,Gandaglia G,et al.Predictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma.Urol Oncol,2014,32(8):1259-66.
11 Schmid M,Krishna N,Ravi P,et al.Trends of acute kidney injury after radical or partial nephrectomy for renal cell carcinoma.Urol Oncol,2016,34(7):293.e1-293.e10.
12 Barlow LJ,Korets R,Laudano M,et al.Predicting renal functional outcomes after surgery for renal cortical tumours: a multifactorial analysis.BJU International,2010,106(4):489-492.
13 王媛媛,谢院生,曹静,等.单肾切除术后肾功能下降的因素.中国中西医结合肾病杂志,2017,18(4):301-304.
14 Leppert JT,Lamberts RW,Thomas IC,et al.Incident CKD after Radical or Partial Nephrectomy.J Am Soc Nephrol,2018,29(1):207-216.
15 Cho A,Lee JE,Kwon GY,et al.Post-operative acute kidney injury in patients with renal cell carcinoma is a potent risk factor for new-onset chronic kidney disease after radical nephrectomy.Nephrol Dial Transplant,2011,26(11):3496-3501.
16 郑玮,寿建忠,马建辉,等.根治性肾切除术后患者肾功能改变的长期观察.中华泌尿外科杂志,2014,35(6):433-437.
17 Ahn T,Ellis RJ,White VM,et al.Predictors of new-onset chronic kidney disease in patients managed surgically for T1a renal cell carcinoma: An Australian population-based analysis.J Surg Oncol,2018,117(7):1597-1610.
18 Dey S,Hamilton Z,Noyes SL,et al.Chronic Kidney Disease Is More Common in Locally Advanced Renal Cell Carcinoma.Urology,2017,105:101-107.
19 Lucas SM,Nuss G,Stern J,et al.The screening for Occult Renal Disease (SCORED) value is associated with a higher risk for having or developing chronic kidney disease in patients treated for small,unilateral renal masses.Cancer,2008,113(10):2681-2686.
2 Kellum JA,Lameire N; KDIGO AKI Guideline Work Group.Diagnosis,evaluation,and management of acute kidney injury:a KDIGO summary.Crit Care,2013 Feb 4,17(1):204.
3 Chawla LS,Bellomo R,Bihorac A,et al.Acute kidney disease and renal recovery:consensus report of the Acute Disease Quality Initiative(ADQI) 16 Workgroup.Nat Rev Nephrol,2017,13(4):241-257.
4 National Kidney Foundation.K/DOQI clinical practice guidelines for chronic kidney disease:evaluation,classification,and stratification.Am J Kidney Dis,2002,39(2 Suppl 1):S1-266.
5 Kopple JD.National kidney foundation K/DOQI clinical practice guidelines for nutrition in chronic renal failure.Am J Kidney Dis,2001,37(1 Suppl 2):S66-70.
6 Hiten DP,Phillip MP,Michael HJ,et al.Renal functional outcomes after surgery,ablation,and active surveillance of localized renal tumors:a systematic review and meta-analysis.Clin J Am Soc Nephrol,2017(12):1057-1069.
7 Shirley DG,Walter SJ.Acute and chronic changes in renal function following unilateral nephrectomy.Kidney Int,1991,40(1):62-68.
8 Chamberlain RM,Shirley DG.Time course of the renal functional response to partial nephrectomy:measurements in consciousrats.Exp Physiol,2007,92(1):251-262.
9 Shin S,Han Y,Park H,et al.Risk factors for acute kidney injury after radical nephrectomy and inferior vena cava thrombectomy for renal cell carcinoma.J Vasc Surg,2013,58(4):1021-1027.
10 Schmid M,Abd-El-Barr AE,Gandaglia G,et al.Predictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma.Urol Oncol,2014,32(8):1259-66.
11 Schmid M,Krishna N,Ravi P,et al.Trends of acute kidney injury after radical or partial nephrectomy for renal cell carcinoma.Urol Oncol,2016,34(7):293.e1-293.e10.
12 Barlow LJ,Korets R,Laudano M,et al.Predicting renal functional outcomes after surgery for renal cortical tumours: a multifactorial analysis.BJU International,2010,106(4):489-492.
13 王媛媛,谢院生,曹静,等.单肾切除术后肾功能下降的因素.中国中西医结合肾病杂志,2017,18(4):301-304.
14 Leppert JT,Lamberts RW,Thomas IC,et al.Incident CKD after Radical or Partial Nephrectomy.J Am Soc Nephrol,2018,29(1):207-216.
15 Cho A,Lee JE,Kwon GY,et al.Post-operative acute kidney injury in patients with renal cell carcinoma is a potent risk factor for new-onset chronic kidney disease after radical nephrectomy.Nephrol Dial Transplant,2011,26(11):3496-3501.
16 郑玮,寿建忠,马建辉,等.根治性肾切除术后患者肾功能改变的长期观察.中华泌尿外科杂志,2014,35(6):433-437.
17 Ahn T,Ellis RJ,White VM,et al.Predictors of new-onset chronic kidney disease in patients managed surgically for T1a renal cell carcinoma: An Australian population-based analysis.J Surg Oncol,2018,117(7):1597-1610.
18 Dey S,Hamilton Z,Noyes SL,et al.Chronic Kidney Disease Is More Common in Locally Advanced Renal Cell Carcinoma.Urology,2017,105:101-107.
19 Lucas SM,Nuss G,Stern J,et al.The screening for Occult Renal Disease (SCORED) value is associated with a higher risk for having or developing chronic kidney disease in patients treated for small,unilateral renal masses.Cancer,2008,113(10):2681-2686.