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End-Stage Kidney Disease Following Surgical Management of Kidney Cancer

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End-Stage Kidney Disease Following Surgical Management of Kidney Cancer Article End-Stage Kidney Disease following Surgical Management of Kidney Cancer Robert J. Ellis ,1,2,3,4 Daniel P. Edey,2,3 Sharon J. Del Vecchio,2,3,5 Megan McStea,3,6 Scott B. Campbell,1,6 Carmel M. Hawley,1,2,6,7 David W. Johnson ,1,2,6,7 Christudas Morais,2,3,5 Susan J. Jordan,4,8 Ross S. Francis,1,2,6,7 Simon T. Wood,2,3,5 Glenda C. Gobe,2,3,9,10 and Cancer Alliance Queensland Abstract 1 Background and objectives We investigated the incidence of ESKD after surgical management of kidney cancer in Departments of Nephrology and the Australian state of Queensland, and described patterns in the initiation of kidney replacement therapy 5Urology, Princess resulting from kidney cancer across Australia. Alexandra Hospital, Brisbane, Australia; 2 Design, setting, participants, & measurements All newly diagnosed cases of kidney cancer in the Australian state of Centre for Kidney Disease Research, Queensland between January of 2009 and December of 2014 were ascertained through the Queensland Cancer Faculty of Medicine, Registry. There were 2739 patients included in our analysis. Patients who developed ESKD were identified using 6Australasian Kidney international classification of disease–10–coded hospital administrative data. Incidence rate and 3-year Trials Network, 8 cumulative incidence were calculated, and multivariable Cox proportional hazards models were used to identify Schools of Public Health and factors associated with ESKD. Additional descriptive analysis was undertaken of Australian population data. 9 Biomedical Sciences, and 10NHMRC Results The incidence rate of ESKD in all patients was 4.9 (95% confidence interval [95% CI], 3.9 to 6.2) per 1000 Chronic Kidney patient-years. The 3-year cumulative incidence was 1.7%, 1.9%, and 1.0% for all patients, and patients managed DiseaseCentrefor with radical or partial nephrectomy, respectively. Apart from preoperative kidney disease, exposures associated Research Excellence, $ University of with increased ESKD risk were age 65 years (adjusted hazard ratio [aHR], 2.0; 95% CI, 1.2 to 3.2), male sex (aHR, Queensland, 2.3; 95% CI, 1.3 to 4.3), preoperative diabetes (aHR, 1.8; 95% CI, 1.0 to 3.3), American Society of Anesthesiologists Brisbane, Australia; classification $3 (aHR, 4.0; 95% CI, 2.2 to 7.4), socioeconomic disadvantage (aHR, 1.6; 95% CI, 0.9 to 2.7), and 3Kidney Disease postoperative length of hospitalization $6 days (aHR, 2.1; 95% CI, 1.4 to 3.0). Australia-wide trends indicate that Research the rate of kidney replacement therapy after oncologic nephrectomy doubled between 1995 and 2015, from 0.3 to Collaborative, Translational Research 0.6 per 100,000 per year. Institute, Brisbane, Australia; 4Cancer Conclusions In Queensland between 2009 and 2014, one in 53 patients managed with radical nephrectomy and one Causes and Care in 100 patients managed with partial nephrectomy developed ESKD within 3 years of surgery. Group, QIMR – Berghofer Medical Clin J Am Soc Nephrol 13: 1641 1648, 2018. doi: https://doi.org/10.2215/CJN.06560518 Research Institute, Brisbane, Australia; and 7Australian and Introduction and 2015, 0.6% of patients who commenced kidney New Zealand Dialysis and Transplant In the developed world, the kidney is the sixth and replacement therapy (KRT) were recorded as having Registry, Adelaide, 13th most common site for primary malignancy in developed ESKD as a consequence of kidney cancer Australia men and women, respectively (1). Surgical manage- (6), which is similar to data from the USA, where ment with either radical (complete) or partial (nephron- kidney cancer patients constituted approximately Correspondence: sparing) nephrectomy is the mainstay of treatment. 0.5% of the KRT population from 1983 to 2007 (7). Mr. Robert J. Ellis, Removaloffunctionalkidneyparenchymacan Globally, the incidence of kidney cancer is rising, Translational Research ’ Institute (Level 5), increase a patient s risk of CKD (2). International particularly in Western countries (8), and in Australia 37 Kent Street, guidelines recommend partial nephrectomy when .3000 patients are diagnosed with kidney cancer Woolloongabba, QLD feasible, due to associations with better postoperative annually (9). Incidence rates have been steadily rising 4102, Australia. Email: kidney function and equivalent oncologic control since the 1980s, but mortality rates have remained [email protected] compared with radical nephrectomy (3,4). This has relatively static (9). It is unclear whether this is led to increased contemporary utilization of partial because patients are receiving more effective treat- nephrectomy (5). ment or whether a diagnosis is being made earlier in For patients who have limited life expectancy, the clinical course of disease; however, considering iatrogenic CKD is less likely to lead to a clinically trends of increasing incidental diagnosis of kidney significant event; however, for patients with a favor- cancer, the latter seems more likely (10,11). Regardless able prognosis, there is increased risk that CKD will of interpretation, these data demonstrate that the lead to a clinically significant end point, such as ESKD number of patients diagnosed with, and subsequently or cardiovascular events. In Australia between 2011 managed surgically for, kidney cancer is increasing www.cjasn.org Vol 13 November, 2018 Copyright © 2018 by the American Society of Nephrology 1641 1642 Clinical Journal of the American Society of Nephrology and that, on average, patients diagnosed with kidney comorbidities, moderate-to-severe CKD and diabetes mel- cancer are expected to live longer. These two factors litus were included in the primary analysis. Sensitivity contribute to an increased lifetime risk of developing analyses were conducted that included additional comor- clinically significant iatrogenic CKD. bidities. Determination of comorbidities was limited to Previous population-based studies from the USA and hospitalizations within 12 preoperative months. American Canada have demonstrated that ESKD incidence after Society of Anesthesiologists (ASA) classification was re- surgical resection of kidney cancer is more common after corded at the time of surgery, and linked to cancer registry radical than partial nephrectomy, and in multimorbid/ data from hospital records, before being provided to elderly patients (12–15). The burden of ESKD after onco- investigators. ASA classification was grouped as 1–2and logical nephrectomy has not been previously evaluated in $3. Urban/rural place of residence and hospital location Australian populations. were assigned on the basis of the Accessibility/Remoteness The primary aim of this study was to characterize the Index of Australia (19). Patients were evaluated by area- burden of postoperative ESKD after radical and partial level socioeconomic status, grouped by tertiles (disadvan- nephrectomy, and to identify associations between patient taged, middle, advantaged) in accordance with the Aus- and health-service characteristics and this outcome, using a tralian Socioeconomic Indexes for Areas (Index of Relative large, population-based cohort of patients managed for Socioeconomic Disadvantage) (20). Patient-level socioeco- kidney cancer in the Australian state of Queensland. The nomic status and urban/rural status were determined from secondary aim was to evaluate long-term nationwide the postcode of the patient’s usual place of residence trends in kidney cancer-associated mortality and KRT recorded in the cancer registry, and provided in the data incidence. extract. Hospital volume was estimated by dividing the total number of surgical resections during the study period at each center by six, as per our previous publication (21). Materials and Methods Postoperative length of stay was calculated as the number Study Design and Population of days between the date of surgery and the date of All patients with any type of newly diagnosed kidney discharge. cancer across 43 hospitals in the Australian state of Queensland, diagnosed between January of 2009 and December of 2014, were ascertained through the Queens- Outcome land Cancer Registry, a state-wide registry that records all The primary outcome was ESKD. The date of ESKD was – newly diagnosed malignancies. Reporting cancer incidence assigned using ICD-10 coded hospital admissions data for to state-based registries is a legal requirement in Australia; any of: ESKD (N18.6), dependence on dialysis (Z99.2), or therefore, ascertainment of all cases is likely close to complete. kidney transplant (Z94.0). Patients undergoing a second There were 3799 patients identified. We excluded those who: radical nephrectomy were considered to have developed were aged ,18 years old (n=47), did not receive surgery ESKD on the date of their second procedure. (n=988), underwent concurrent bilateral nephrectomy (n=8), or had ESKD before surgery (n=17). The final sample in- Descriptive Analysis cluded 2739 patients. Patients younger than 18 years old were Additional data were obtained to descriptively evaluate excluded because it is likely that there are physiologic nationwide trends in kidney cancer–associated mortality differences in the response to nephrectomy between children and KRT. Incidence and mortality rates for kidney cancer in and adults (16). Patients who had ESKD before surgery were Australia were obtained from the Australian Institute of identified using international classification of disease–10 Health and Welfare (projected values used for 2016) (9,22), (ICD-10)–coded hospital administrative data. and KRT incidence data were provided
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