Chronic kidney disease after nephroureterectomy for upper tract urothelial carcinoma and implications for the administration of perioperative chemotherapy.
BACKGROUND
The prevalence of chronic kidney disease (CKD) in patients with upper tract urothelial carcinoma (UTUC) is poorly defined, both before and after nephrouretectomy. Although multimodal treatment paradigms for UTUC are under-developed, this has important implications on patients' ability to receive cisplatin-based combination chemotherapy (CBCC).


METHODS
Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula in 336 patients with UTUC, who were treated at the Cleveland Clinic by nephroureterectomy since 1992. An eGFR cutoff of 60 mL/min/1.73 m(2) was used to determine the presence of CKD and eligibility for CBCC.


RESULTS
Median age was 72 years and median preoperative eGFR was 59 mL/min/1.73m(2). Before nephroureterectomy, only 48% of patients were eligible to receive CBCC and this decreased to 22% postoperatively (P < .001). In the 144 patients with pT2-pT4 and/or pN1-pN3 disease who are suitable to receive CBCC, these proportions were 40% and 24%, respectively (P = .009). Although 50 patients overall received some form of perioperative chemotherapy, only 3 and 11 patients received neoadjuvant and adjuvant CBCC, respectively.


CONCLUSIONS
CKD is prevalent in the UTUC population and a minority of patients has an optimal eGFR to receive neoadjuvant CBCC. Nephrouretectomy may eliminate CBCC as a therapeutic option in 49% of high-risk patients if it is deferred to the adjuvant setting. Multimodal treatment strategies for UTUC should focus on neoadjuvant chemotherapy, as few patients are eligible for adjuvant CBCC because of the substantial decline in eGFR caused by nephroureterectomy.
Lane
Brian R
BR
Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Smith
Armine K
AK
Larson
Benjamin T
BT
Gong
Michael C
MC
Campbell
Steven C
SC
Raghavan
Derek
D
Dreicer
Robert
R
Hansel
Donna E
DE
Stephenson
Andrew J
AJ
D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant; D002945:Cisplatin / Q000627:therapeutic use; D003131:Combined Modality Therapy; D004317:Doxorubicin / Q000627:therapeutic use; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007676:Kidney Failure, Chronic / Q000209:etiology / Q000517:prevention & control*; D007680:Kidney Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009392:Nephrectomy / Q000009:adverse effects*; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D014747:Vinblastine / Q000627:therapeutic use
D014747:Vinblastine; D004317:Doxorubicin; D002945:Cisplatin; D008727:Methotrexate