Is partial nephrectomy underutilised in diabetic patients at risk for CKD?

Friday, 3 June 2011- A major benefit of partial nephrectomy (PN) over radical nephrectomy (RN) is greater preservation of kidney function. Emerging evidence also suggests that chronic kidney disease (CKD) correlates with survival, likely as a result of increased cardiovascular morbidity.

Diabetes Mellitus (DM) followed by Hypertension (HTN) are the two most frequent causes of end-stage renal disease (ESRD). Given the strong association between renal functional decline and the surgical treatment of small renal masses, one would expect utilisation of PN in patients with HTN or DM to be high, however minimal data exist on PN use in these populations. Thus it has not been determined whether these patients are being managed optimally.

R. Abouassaly and colleagues conducted a large study to demonstrates that PN is being underutilised in patients at risk for CKD, particularly patients with Diabetes Mellitus and Hypertension. Unlike previously published reports, the population-level study provides a description of the landscape of care for patients with renal masses in general practice, and does not simply reflect treatment patterns at tertiary referral centres.

"The finding of low PN use in patients at risk for CKD deserves further study. Future studies should focus on determining the specific factors contributing to PN underutilisation in these susceptible patients, as well as developing clinical tools to reliably identify those patients in whom the benefits of PN outweigh the risks," the authors wrote in an online edition of BJU International.

In their study the researchers aimed to determine partial nephrectomy (PN) use in patients at risk of chronic kidney disease (CKD), such as those with diabetes mellitus (DM) and hypertension (HTN).

They conducted a national, population-based, retrospective, observational study using the Canadian Institute for Health Information Discharge Abstract Database. The investigators included all patients treated surgically for renal cell carcinoma from 1 April 1998 to 31 March 2008. Patients with DM and HTN were identified using specific diagnosis codes. The proportions of patients treated with PN were compared in patients with and without DM and HTN using multivariable logistic regression adjusting for covariates.

A total of 24 579 patients were treated for a renal mass; of these, 4,292 (17.5%) underwent PN. In the sample, 5,613 (22.8%) patients were identified as having HTN, and 2,738 (11.1%) were identified as having DM. PN was used in 17.3% of patients with HTN compared to 17.5% of those without HTN, whereas, in patients with DM, PN was used in 18.6% compared to 17.3% of patients without DM.

After adjusting for covariates, neither HTN, nor DM were found to be independently associated with increased PN use (odds ratio, 1.07; 95% CI, 0.98–1.16 and odds ratio, 1.08; 95% CI, 0.96–1.20, respectively).

"In this contemporary national analysis, PN appears to be underutilised in DM and HTN, despite their known relationship with chronic renal failure," the researchers concluded. "Further studies are needed to elucidate the specific factors contributing to PN underutilisation in these susceptible patients."

Source: R. Abouassaly, et al., "How often are patients with diabetes or hypertension being treated with partial nephrectomy for renal cell carcinoma? A population-based analysis," BJU International; DOI: 10.1111/j.1464-410X.2011.10254.

Edited by: JV

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