Scleroderma at end stage renal disease in the United States: patient characteristics and survival

BACKGROUND: The patient characteristics and mortality associated with scleroderma have not been characterized for a national sample of end stage renal disease (ESRD) patients. METHODS: 364,317 patients in the United States Renal Data System initiated on ESRD therapy between 1 January 1992 and 30 June 1997 with valid causes of ESRD were analyzed in an historical cohort study of scleroderma. RESULTS: Of the study population, 820 (0.22%) had scleroderma. The mean age of patients with scleroderma was 56.38 +/- 13.93 years vs. 60.48 +/- 16.51 years for patients with other causes of ESRD (p<0.01 by Student's t-test). In histogram analysis, there were two age peaks: 45-49 and 65-69. In logistic regression, patients with scleroderma, compared to patients with other causes of ESRD, were significantly more likely to be women, Caucasian, younger, and more likely to have congestive heart failure but less likely to have ischemic heart disease, stroke, and receive predialysis erythropoietin. The unadjusted two-year survival of patients with scleroderma during the study period was 49.3% vs. 63.8% in all other patients (adjusted hazard ratio, 1.96, 95% CI 1.70-2.26, p=0.0001 by Cox Regression). CONCLUSIONS: Among patients with ESRD, the demographics of patients with scleroderma were similar to those of patients with scleroderma in the general population. Patients with scleroderma had decreased survival compared to patients with other causes of ESRD, despite being equally likely to be wait listed and receive renal transplantation adjusted for other factors.     

Sickle cell nephropathy at end-stage renal disease in the United States: patient characteristics and survival

BACKGROUND: The patient characteristics, including age at presentation to end-stage renal disease (ESRD) and mortality associated with sickle cell nephropathy (SCN) have not been characterized for a national sample of patients. METHODS: 375,152 patients in the United States Renal Data System were initiated on ESRD therapy between January 1, 1992 and June 30, 1997 and analyzed in an historical cohort study of SCN. RESULTS: Of the study population, 397 (0.11%) had SCN, of whom 93% were African-American. The mean age at presentation to ESRD was 40.68+/-14.00 years. SCN patients also had an independently increased risk of mortality (hazard ratio 1.52, 95% CI: 1.27-1.82) even after adjustment for placement on the renal transplant waiting list, diabetes, hematocrit, creatinine, and body mass index. However, when receipt of renal transplantation was also included in the model, SCN was no longer significant (p = 0.51, HR = 1.10, 95% CI: 0.82-1.48). SCN patients were much less likely to be placed on the renal transplant waiting list or receive renal transplants in comparison to age and race matched controls, and results of survival analysis were similar in this model. CONCLUSIONS: SCN patients were much less likely to be listed for or receive renal transplantation than other comparable patients with ESRD. SCN patients were at independently increased of mortality compared with other patients with ESRD, including those with diabetes, but this increased risk did not persist when models adjusted for their low rates of renal transplantation.     

Polycystic kidney disease at end-stage renal disease in the United States: patient characteristics and survival

BACKGROUND: The patient characteristics and mortality associated with autosomal dominant polycystic kidney disease have not been characterized for a national sample of end-stage renal disease (ESRD) patients. METHODS: 375,152 patients in the United States Renal Data System were initiated on ESRD therapy (including patients who eventually received renal transplants) between January 1, 1992 and June 30, 1997 and analyzed in an historical cohort study of polycystic kidney disease. RESULTS: Of the study population, 5,799 (1.5%) had polycystic kidney disease. In logistic regression, polycystic kidney disease was associated with Caucasian race (odds ratio 3.31, 95% CI, 3.09-3.54), women (1.10, 1.04-1.16), receipt of renal transplant (4.15, 3.87-4.45), peritoneal dialysis (vs. hemodialysis, 1.37, 1.27-1.49), younger age, and more recent year of first treatment for ESRD. Use of pre-dialysis EPO but not the level of serum hemoglobin at initiation of ESRD was significantly higher in patients with polycystic kidney disease. Patients with polycystic kidney disease had lower mortality compared to patients with other causes of ESRD, but patients with polycystic kidney disease had a higher adjusted risk of mortality associated with hemodialysis (vs. peritoneal dialysis) compared to patients with other causes of ESRD (hazard ratio 1.40, 1.13-1.75). CONCLUSIONS: Hematocrit at presentation to ESRD was not significantly different in patients with polycystic kidney disease compared with patients with other causes of ESRD. Peritoneal dialysis is a more frequent modality than hemodialysis in patients with polycystic kidney disease, and patients with polycystic kidney disease had an adjusted survival benefit associated with peritoneal dialysis, compared to patients with other causes of renal disease.     

Retroperitoneoscopic radical and partial nephrectomy in the patient with cirrhosis

PURPOSE: In patients with cirrhosis and a renal mass options may be limited by medical disease and the surgical difficulties associated with portal hypertension. We describe a retrospective review of patients with cirrhosis with renal masses who underwent radical or partial nephrectomy through a retroperitoneoscopic approach. MATERIALS AND METHODS: Ten consecutive patients, including 4 men and 6 women, with cirrhosis, of whom 2 had undergone liver transplantation, underwent radical (7) or partial (3) nephrectomy for a total of 5 right and 5 left renal neoplasms via the retroperitoneoscopic approach at our institution from March 2002 to February 2004. Recovery data were prospectively obtained and other information was gathered retrospectively from the medical record. RESULTS: Average patient age was 58 years and average American Society of Anesthesiology score was 2.8. Average renal tumor size for radical and partial nephrectomy was 4.6 (range 2.9 to 7) and 1.8 cm (range 1.3 to 2.3), respectively. Operative time was 140 to 315 minutes (median 172) and estimated blood loss was 100 to 5,000 ml (median 225). One patient required open conversion due to hemorrhage from left portosystemic venous communications. Mean postoperative hospitalization was 1.5 days (range 1 to 6). CONCLUSIONS: Although retroperitoneoscopic surgery avoids many surgical dangers associated with portal hypertension and it is our preferred approach to renal surgery in patients with cirrhosis, significant portosystemic venous communications exist in the retroperitoneum, especially on the left side, and they still lead to substantial blood loss in some patients.     

Prospective study of robotic partial nephrectomy for renal cancer in Japan: Comparison with a historical control undergoing laparoscopic partial nephrectomy

Objectives

To evaluate the outcomes of robotic partial nephrectomy compared with those of laparoscopic partial nephrectomy for T1 renal tumors in Japanese centers.

Methods

Patients with a T1 renal tumor who underwent robotic partial nephrectomy were eligible for inclusion in the present study. The primary end‐point consisted of three components: a negative surgical margin, no conversion to open or laparoscopic surgery and a warm ischemia time ≤25 min. We compared data from these patients with the data from a retrospective study of laparoscopic partial nephrectomy carried out in Japan.

Results

A total of 108 patients were registered in the present study; 105 underwent robotic partial nephrectomy. The proportion of patients who met the primary end‐point was 91.3% (95% confidence interval 84.1–95.9%), which was significantly higher than 23.3% in the historical data. Major complications were seen in 19 patients (18.1%). The mean change in the estimated glomerular filtration rate in the operated kidney, 180 days postoperatively, was ?10.8 mL/min/1.73 m² (95% confidence interval ?12.3–9.4%).

Conclusions

Robotic partial nephrectomy for patients with a T1 renal tumor is a safe, feasible and more effective operative method compared with laparoscopic partial nephrectomy. It can be anticipated that robotic partial nephrectomy will become more widely used in Japan in the future.

     

Laparoscopic donor nephrectomy in a patient with previous upper pole partial nephrectomy

A 56-year-old woman underwent laparoscopic partial nephrectomy for symptomatic angiomyolipoma. She then donated her remaining ipsilateral kidney for renal transplantation. The allograft had good, immediate function in the recipient. This is the first reported case of a patient undergoing renal donor nephrectomy after partial nephrectomy for angiomyolipoma.     

The burden of illness associated with renal cell carcinoma in the United States

BACKGROUND: There were over 36,000 new cases of kidney cancer reported in the United States in 2004, the most common type being renal cell carcinoma (RCC). Available treatments for localized RCC frequently lead to cure; however RCC patients with advanced disease have limited treatment options and low survival rates. Data on the economic burden of RCC are limited. METHODS: A prevalence-based model was used to estimate the aggregate annual societal cost burden of RCC in the U.S., including costs of treatment and lost productivity. Key parameters in the model include: the annual number of patients treated for RCC by age group and cancer stage; utilization of cancer treatments; unit costs; work-days missed; and wage rates. Multiplying stratum-specific distributions of treatment by annual quantities of treatments and unit costs yields estimates of RCC-related health-care costs. Multiplying stratum-specific estimates of annual workdays missed by average wage rates yields estimates of RCC-related lost productivity. RESULTS: The annual prevalence of RCC in the U.S. was estimated to be 109,500 cases. The associated annual burden (inflated to 2005 U.S.$) was approximately $4.4 billion ($40,176 per patient). Health-care costs and lost productivity accounted for 92.4% ($4.1 billion) and 7.6% ($334 million), respectively. Reflecting its higher prevalence, the total cost associated with localized RCC accounted for the greatest share (78.2%), followed by regional, distant, and unstaged RCC, at 18.3%, 2.8%, and 0.7%, respectively. CONCLUSIONS: The economic burden of RCC in the U.S. is substantial. Interventions to reduce the prevalence of RCC have the potential to yield considerable economic benefits.     

Laparoscopic partial nephrectomy: risk stratification according to patient and tumor characteristics

Purpose

Laparoscopic partial nephrectomy (LPN) is the treatment of choice for localized tumors in many centers. We aimed to evaluate differences in complication rates and outcome stratified by risk categories, depending on patient or tumor characteristics.

Methods

Eighty-one patients who underwent LPN for localized renal tumors between 2004 and 2007 were evaluated. Clinical and pathological data, including localization, size and infiltration depth (classified according to PADUA and RENAL score), at initial radiologic imaging were analyzed. Results were correlated with complications during or after surgery, operative time, warm ischemia time and clinical outcome.

Results

Overall complication rate was 13.6% for LPN (11 patients, Clavien-Dindo classification: II–III). No significant correlations were found for patient-based risk classification models (age?>?70?years, ASA-status?>2, BMI?>?30). A higher mean operative time was observed in centrally located tumors (P?=?0.045). Increased hemoglobin loss was observed in central (P?=?0.007), PADUA?>?8 (P?=?0.006) and RENAL?>?7 (P?=?0.002) tumors. Impaired renal function (creatinine increase in postoperative controls) was associated with tumor diameter?>?4?cm (P?=?0.023). Only central tumor growth had a significant predictive value for postoperative complications (P?=?0.007). In patients with central tumor growth (P?=?0.002), PADUA?>?8 (P?=?0.041) and RENAL?>?7 (P?=?0.044) scores, hospital stay was prolonged.

Conclusions

Uni and multifactorial scoring systems have been developed for LPN to identify potentially high-risk patients. In our series, only central tumor growth pattern enabled the prediction of increased operation time, hemoglobin loss, hospitalization as well as postoperative complications.     

Experience with partial nephrectomy for renal cell carcinoma

From Sept. 1991 to Jan. 1999, we performed partial nephrectomy on 7 patients with renal cell carcinoma. The indication was imperative for 3 patients, and elective for 4 patients. The 3 imperative cases consisted of bilateral renal cell carcinomas, a polycystic kidney disease and a contralateral atrophic kidney. All 4 patients with elective indication revealed renal cell carcinoma with a normal functioning contralateral kidney. The tumor size ranged from 1.3 cm to 6.0 cm (2.7 cm on average). The mean clamping time of renal artery was 22 minutes and mean blood loss was 400 ml. The pathological stage was pT1a in 6 patients and pT1b in one patient. Postoperative follow-up ranged from 4 months to 92 months (mean: 43 months). One patient with bilateral renal cell carcinoma died of metastases to the lungs and brain at 25 months postoperatively. The remaining 6 patients are alive without recurrence and metastasis. We obtained a good postoperative course in our selected patients with low stage. Thus it was considered that partial nephrectomy is effective against small renal cell carcinoma.