Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy.
Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy.
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DOI：
10.1016/j.eururo.2010.06.029
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发表时间：
2010-10
期刊：
影响因子：
23.4
通讯作者：
Huang, William C.
中科院分区：
文献类型：
--
作者：
Kaag, Matthew G.;O'Malley, Rebecca L.;O'Malley, Padraic;Godoy, Guilherme;Chen, Mang;Smaldone, Marc C.;Hrebinko, Ronald L.;Raman, Jay D.;Bochner, Bernard;Dalbagni, Guido;Stifelman, Michael D.;Taneja, Samir S.;Huang, William C.
关键词：
单纯肾输尿管切除术不能充分治疗许多晚期上尿路上皮癌（UTUC）患者。已提出围手术期铂类化疗，但需要足够的肾功能。我们的目的是确定肾输尿管切除术后铂类药物化疗的能力是否受到术后肾功能变化的影响。我们回顾性分析了1991年至2009年间388例因UTUC接受肾输尿管切除术的患者的资料。其中包括四个机构。所有患者均行肾输尿管切除术。所有患者在手术前后均测量血清肌酐。取最接近术后3个月的值作为术后值（范围：2[en]52周）。使用简化的肾脏疾病饮食改良研究公式计算估计的肾小球滤过率（eGFR）。使用配对t检验比较手术前后的EGFR值。我们选择eGFR为45和60 ml/min/1.73 m2作为化疗合格性的可能截止值，并使用卡方检验比较手术前后的合格性。我们的388例患者包括233例男性（60%），中位年龄为70岁。手术后平均eGFR降低了24%。使用60 ml/min/1.73 m2的临界值，49%的患者在术前有资格接受化疗，但只有19%的患者在术后仍有资格接受化疗。使用45 ml/min/1.73 m2的临界值，80%的患者术前合格，但术后仅55%合格。当我们将分析限于晚期病理分期（T3或更高）患者时，这种分布仍然存在。年龄大于70岁的患者更有可能在术前和术后不适合化疗，并且无论其起始eGFR如何，他们术后eGFR <45 ml/min/1.73 m2的可能性显著更大。本研究受其回顾性性质的限制，并且术后血清肌酐测量的时间存在一些变异性。EGFR在肾输尿管切除术后显著减少，特别是在老年患者中。肾功能的这些变化可能影响辅助顺铂治疗的合格性。因此，我们建议强烈考虑新辅助治疗方案。
Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. All patients underwent nephroureterectomy. All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2[en]52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. EGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m2 as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test. Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m2, 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m2, 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m2 postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements. EGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens.
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