Long-term serum creatinine valuesafter radical nephrectomy

Long-term serum creatinine valuesafter radical nephrectomy

LONG-TERM SERUM CREATININE VALUES AFTER RADICAL NEPHRECTOMY KENNETH I. WISHNOW, M.D. DOUGLAS E. JOHNSON, M.D. DIGBY PRESTON, B.S. DENISE TENNEY, R.N. ...

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LONG-TERM SERUM CREATININE VALUES AFTER RADICAL NEPHRECTOMY KENNETH I. WISHNOW, M.D. DOUGLAS E. JOHNSON, M.D. DIGBY PRESTON, B.S. DENISE TENNEY, R.N. From the Department of Urology, The University of Texas M.D. Anderson Cancer Center at Houston, Texas

ABSTRACT--Both pre- and postnephrectomy levels of serum creatinine were measure, secutive patients who underwent radical nephrectomy for localized renal cell carcinm 1971 and 1976. At the time of follow-up, 17 patients were alive and 35 had died, 14 carcinoma and 21 of other causes. Follow-up lasted a minimum of 115.5 months (: months, median 141.1, range 115.5-211.3 months) for 16 of the 17 patients who were c group only 2 patients had elevations in the serum creatinine level above 1.6 mg/dL--1.9 2.4 mg/dL, respectively. The patient whose value was 2.4 mg/dL was a diabetic m insulin. NO serious renal failure, renal disease, or tumors in the contralateral kidn, among the' total group of 52 patients. These data indicate that renal function remains patients who have a normal contralateral kidney and are treated by radical nephrect.

For years parenchyma-conserving surgery, such as partial nephreetomy, tumor enucleation, or wedge resection, has been recommended for patients who have tumor in a solitary kidney, bilateral renal tumors, or compromised renal function. 1 However, because many urologists believe that radical nephreetomy is generally safer and ,easier to perform and results in lower recurrence rates than parenchyma-conserving surgery, it has been the preferred treatment for the majority of patients who have renal cell eareinoma and a normal contralateral kidney.2~3 Recently, however, several authorities have questioned this practice. They believe that parenehyma-conserving surgery rather than radical nephreetomy should be the preferred treatment for renal carcinoma, even when patients have a normal eontralateral kidney.4-6 Their main argument is that the potential benefits of preserving renal function in the affected kidney outweigh the increased risk of recurrenee or morbidity after parenchyma-eonserving surgery.

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But is this argument valid? ' fects of radical nephreetomy or function in the patient with a lateral kidney? To answer th evaluated renal function by re~ recent serum ereatinine values, patients with localized renal who were treated by radical the urology service at The Un M.D. Anderson Cancer Cente: tween 1971 and 1976. Material and Methods During the period 197: nephrectomies were perforr nal cell carcinoma on the ul M.D. Anderson Hospital. ~ excluded from analysis, eith follow-up (1 patient) or [ were not available for revi, *Patient population identified throe maintained by the department of patient studies.

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TABLE I.

Long-term serum creatinine after radical nephrectomy

Pt. Nephrec. No. Date 1 4-01-70 2 7-21-70 3 7-07-71 4 11-02-71 5 12-28-71 6 4-18-72 7 11-14-73 8 7-06-75 9 9-12-75 10 9-12-75 11 3-29-76 12 6-17-76 13 7.12-76 14 8-27-76 15 11-09-76 I6 12-17-76 Mean

Stage I II III (vein) III (vein) I III (vein) I III (vein) I III (vein) I I I II I I

Serum Creatinine --Value (mg/dL)-PreFollownephree. Up 1.4 1.5 1.4 1.2 . . 1.3 1.2 1.6 1.0 1.5 1.3 1.6 1.0 1.1 1.3 2.4 1.1 1.9 1.1 1.5 1.3 1.4 1.2 1.4 1.1 1.2 1.1 1.4 1.1 1.2 0.7 1.0 1.2 1.5

.ords of the remaining 52 pane the rate of development of ,rs in the eontralateral kidney m effects of radical nephreenction. the patients were men and 20 eir mean age was 57.8 years mge 35.0-76.8). The original osis was made by our patholusing the Robson system for ag. 2 Twenty-seven of the tulogic Stage I, 9 were Stage II, ,~e III (13 invading the vein, 3 an size of the tumors' single ~¢as 8.3 cm (median 8.0, range 9gic types were: clear cell carmlar cell, 1; other, 1. Results t the time of follow-up 17 patients were i and 35 had died. Sixteen of the 17 living ~ts h a d been monitored for a m i n i m u m of 5 months (mean 151.1 months, median 1months, range 115.5 to 211.3). Pre- and aephrectomy data for these 16 patients, in!ing serum ereatinine values, are shown in [ei, At the time of follow-up the mean tna ereatimne value was 1.5 mg/dL (median rng/dL, range 1.0 to 2.4 mg/dL). Only 2 !ents had serum creatinine values higher ! i . 6 rng/dL--1.9 mg/dL and 2.4 mg/dL, )eetive, ly. T h e p a t i e n t w i t h a s e r u m

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Follow-Up Duration (Mos) 210 210 192 180 150 186 144 132 144 144 138 138 132 132 126 114 154.5

Age at Follow-Up (Yrs) 60.4 52.5 88.5 68.0 61.2 70.4 62.0 78.9 75.3 74.2 72.0 60.7 56.4 71.6 58.6 60.9 67.0

creatinine value of 2.4 mg/dL was a diabetic who required insulin. All 16 patients had undergone a follow-up intravenous urogram (IVU), which showed no abnormalities. The IVU was performed a mean of 77.4 months (median 80.9 months, range 13.8-171.3 months) after nephreetomy. Among the 35 patients who had died at the time of follow-up, 14 had died of renal cell carcinoma and 21 of other causes. A postoperative serum creatinine evaluation was performed prior to death in all these patients after a mean follow-up period of 47.9 months (median 41.4 months, range 2.3-144.5 months). At that time the mean serum creatinine level was 1.5 mg/dL (median 1.4, range 0.8-3.0 mg/dL). Seven patients had a serum ereatinine elevation greater than 1.6 mg/dL at the last determination. None had any recognized serious postoperative renal disease or renal failure. No new- tumors developed in the remaining kidney. Comment Although radiation, chemotherapy, and biologic response modifiers are frequently used to treat renal cell carcinoma, surgery is the only curative therapy at the present time. Since patients with tumor recurrence can rarely be salvaged, it is essential to use the optimum surgical approach for each patient. A radical nephrectomy, with or without regional lymphadenectomy, is the standard

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treatment for localized renal cell carcinoma when the patient has a normal eontralateral kidney. W h e n tumors are bilateral or occur in a solitary kidney or w h e n the patient's renal function is compromised, surgery that preserves renal function may be appropriate, v'8 Recently, however, several authorities have recommended parenehyma-eonserving surgery for selected patients even w h e n their eontralateral kidney is normal. 4-6 Although several variables are important for evaluating total renal function, the serum ereatinine level is one of the most useful clinical measurements; significant renal failure is rare w h e n the serum ereatinine level is less than 1.6 mg/dL in an adult. Among our series of 16 evaluable patients who were alive and had been monitored for at least ten years after radical nephreetomy, in only 2 were the serum ereatinine levels elevated above 1.6 mg/dL, 1 at 1.9 mg/dL and 1 at 2.4 mg/dL. Tihe elevation to 2.4 m g / d L occurred in a patient who was a diabetic and required insulin. Among the total group of 52 patients there were no instances of serious renal failure or serious subsequent renal disease. Although the incidence of renal cell carcinoma in a eontralateral kidney is reported in the literature as varying between 1 and 4 percent, this occurred in none of our patients. In fact, although nephreetomy can cause profound alterations in renal physiology, 9 our data show that the majority of patients do not suffer serious renal failure after radical nephreetomy when their eontralateral kidney is normal. We believe that these data are relevant to the present debate c o n c e r n i n g w h e t h e r or not parenehyma-eonserving surgery should be used routinely for patients with small tumors w h e n the contralateral kidney is normal. We acknowledge that parenehyma-eonserving sur-

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gery may be appropriate for the v tient with a very small well-c peripheral lesion. We also aekno,~ cent technical advances have ehyma-eonserving surgery safer m tive. However, we see no eonvin that it should be used routinely fo~ have a normal eontralateral ki& show that, for the majority of have a normal contralateral ki~ treated by radical nephreetomy, : as measured by serum ereatinine adequate. Department of Ur UT M.D. Anderson 1515 Holcc Houst, (D: References 1. Topley M, Novick AC, and Montie JE: Long-term re following partial nephrectomy for localized renal aden cinoma, J Urol 131:1050 (1984), 2. Robson C], Churchill BM, and Anderson W: The resla] radical nephrectomy for renal cell carcinoma, I Urol 1•i'i

(1969).

3. Skinner DG, et ah Diagnosis and management of renal einoma: a clinical and pathologic study of 309 cases, Canc~ 1165 (1971). 4.\ Vermooten V: Indications for conservative surgery in ce renal tumors: a study based on the growth pattern of the cle~ii carcinoma, J Urol 64:200 (1950). 5. Marberger M, et ah Conservative surgery of renal! einoma: the EIRSS experience, Br J Urol 53:528 (1981). 6. Staehler G, and Ernst G: Organerhaltende operativelY] pie bei Nierentumoren, Urologe A 24:330 (1985). ~! 7. Rosenthal CJ, Kraft R, and Zingg EJ: Organ-preserv~i gery in renal cell carcinoma: tumor enueleation versus parfi$1:! lney resection, Eur Urol 1O: 222 (1984). 8. Marshall FF, and Walsh PC: in situ management Of!t tumors: renal cell carcinoma and transitional cell carcinb~i Urol 131. 1045 (1984L 9. Meyer TW, Harris RC, and Brenner BM: Nephron a ~ t.ions to renal injury, in Brenner BM, Rector FC Jr ( E d s ) ~ Kidney, Philadelphia, W.B. Saunders, 1986, pp 1553-15857

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