The Importance of Nephron- sparing/Focal Therapy: Renal Function - PowerPoint PPT Presentation

The Importance of Nephron- sparing/Focal Therapy: Renal Function Preservation Jeffrey A. Cadeddu, M.D. Professor of Urology and Radiology UT Southwestern Medical Center Dallas, TX

Why is maintaining GFR important? Clinical impact: Increased cardiovascular death Weiner et al, 2004 N = 22,634, pooled from 4 community studies (composite includes MI, fatal CHD, nonfatal and fatal stroke, mortality)

Clinical impact: Increase in mortality, morbidity Go et al NEJM, 2004

Clinical impact: Complications of CKD N = 10,162: Third national health and nutrition evaluation survey Stevens et al, 2006

Impact of Preserving GFR in Patients with Renal Tumors • Huang, Russo et al. J Urol 181:55, 2009 – 2500 RN vs. 500 PN (SEER and Medicare)

Mortality Risk of Treatment • Hollingsworth et al. Cancer 109:1763, 2007 – Competing risk analysis 26,000 pts • T1a – 5% risk death w/i 5 years • T2 – 27% risk death w/i 5 yrs, despite surgery • > 70 yo, 28% competing-cause mortality, regardless tumor size • Saving kidney function more likely to impact survival!!!

Renal Preservation: Cryo • Bourne et al. J Endourol 2009 – Lap Cryo (n = 77) • 14 with CRI – MDRD CrCl = 32

Renal Fcn after Cryoablation Series No. Pts. Mean Mean f/u Solitary Preop Postop Tumor size (mo) kidneys renal Renal (range) function function (cm) Carvalhal et 22 2.1 21 No 78.5 ml/min 84.5ml/min al 2001 Schwartz et 84 2.6 (1.2-4.7) 10 No 1.18 mg/dL 1.19 mg/dL al 2006 Finley et al 19 3.0 (1.1-5.4) 13 No 1.2 mg/dL 1.4 mg/dL 2008- lap Finley et al 18 2.7 (1.7-4.7) 11 No 1.2 mg/dL 1.2 mg/dL 2008- perc Munver et al 11 2.6 (1.2-4.3) 43 Yes 1.43 mg/dL 1.57mg/dL 2008 Shingleton et 12 3.1 16 Yes 1.80 mg/dL 1.87 mg/dL al 2003

Renal Fcn after RFA Series No. Pts. Mean Tumor Mean f/u Solitary Preop Postop size (range) (mo) kidneys renal Renal (cm) function function Stern et al 63 2.1 (1.0-4.0) 34 No 76.3 74.3 ml/min/1.73m 2 ml/min/1.73m 2 2009 Ukimura et al 8 3.8 (20-53) 17 No Mean change -0.05 mg/dL 2004 Hoffmann et 10 2.7 (1.9-4.2) 3-24 Yes 79 ml/min 71 ml/min al 2009

Renal Function Impact of Ablation in Solitary Kidney • Raman et al. Can J Urol, 2009 . No. pts 16 Pre-ablation pathology (%) No. tumors 21 Renal cell carcinoma 16 (76) Gender (male/female) 12/4 Oncocytoma 2 (10) Age, yrs 66.1 Non-diagnostic 2 (10) (range) (52.3-81.4) No biopsy 1 (5) Radiographic tumor size, 2.6 Follow-up (mos) cm (1.1-4.0) Mean 30.7 (range) Range 1.5 – 66.0 Tumor location 1 (%) GFR (mL/min/1.73m 2 ) Exophytic 10 (48) Mesophytic 4 (19) Pre-op Endophytic 7 (33) Mean 53.5 Approach (%) Range 22.7 – 89.9 Percutaneous 12 (75) Last F/U Laparoscopic 4 (25) Mean 47.2 Length of stay (days) Range 16.0 – 76.7 Mean (range) 0.75 (0-3) % change from baseline 11.8

Renal Preservation: T1a Tumors Treated by Ablation or Resection (Lucas, Raj et al, J Urol 179:75, 2008)

RENAL PRESERVATION: Outcomes for T1a Tumors Treated by Ablation or Resection (Lucas et al, J Urol 179:75, 2008)

Renal Function Impact of RFA vs. PN in Solitary Kidney • Raman, Matin, Leveillee et al. BJUI 2010 RFA OPN p value (n=33) (n=31) CT tumor size (cm) 0.02 † Median (range) 2.9 (2.0 - 4.0) 3.2 (2.0 – 4.0) No. endophytic tumors 1 (%) 11 (33) 12 (39) 0.65 Median % GFR change (IQR) 0.003 † Last follow-up - 12.9 (18) - 26.3 (31) 0.01 † 0-3 Months follow-up - 6.9 (14) - 14.1 (22) 0.003 † 12 Months follow-up - 11.2 (15) - 22.4 (27) Dialysis dependent < 3mos 0/33 1/31 0.30 from intervention (0%) (3.2%)

Clinical, Pathologic and Functional Outcomes after Nephron-Sparing Surgery in Patients with a Solitary Kidney: A Multi-center Experience Mues, et al. (in submission) Columbia University • University of Florida • UT Southwestern OPN (50) • • UC Irvine LPN (50) • • AMC, Amsterdam Lap Cryo (50) • • Long Island Jewish NY Perc Cryo (28) • • Hackensack University Lap RFA (11) • • Medical Center Perc RFA (16) • University of Wisconsin • Duke University • University of Chicago • Ochsner Clinic • University of Michigan •

Variable Ablation Partial p value Nephrectomy # patients 98 100 # procedures 105 100 ─ Mean age (years) 64 64 0.85 Mean BMI 29 29 0.93 Mean tumor size 2.5 3.9 <0.001 (cm) Mean pre-op 1.4 1.4 0.65 creatinine (mg/dL)

Ablation Partial Nephrectomy Time p value Estimated GFR* Estimated GFR* (mL/min/1.73m 2 ) (mL/min/1.73m 2 ) Pre-operative 59 59 0.91 3 months 52 53 0.76 12 months 51 52 0.78

Renal Function Preservation is Important • Standard surgical treatments increase risk of developing CKD • Focal therapy (RFA or Cryo) may have smallest impact on long term renal function