Joseph Abraham

Impact of Comorbidities on Functional Recovery from Partial Nephrectomy

Purpose: Parenchymal mass preservation, and ischemia type and/or duration can influence functional recovery after partial nephrectomy. Some groups have hypothesized that relevant comorbidities may also impact nephron stability and functional recovery but this has not been adequately investigated. Materials and Methods: At our center 405 patients treated with partial nephrectomy from 2007 to 2015 had the necessary data to determine the function and parenchymal mass preserved in the ipsilateral kidney. Comorbidities potentially associated with renal functional status were reviewed, including various degrees of hypertension, diabetes, cardiovascular disease, obesity, smoking status and related medications. Multivariable linear regression was done to assess factors associated with functional recovery, defined as the percent of preserved ipsilateral glomerular filtration rate. Results: Median tumor size was 3.5 cm and the median R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and tumor touching main renal artery or vein) score was 8. Warm and cold ischemia were done in 264 (65%) and 141 patients for a median duration of 21 and 27 minutes, respectively. The median preserved ipsilateral glomerular filtration rate was 79%. Patient age, comorbidity index, hypertension and proteinuria were each associated with the preoperative glomerular filtration rate (all p <0.01). On univariable and multivariable analyses the preserved parenchymal mass, and ischemia type and duration were significantly associated with functional recovery (all p <0.001). On univariable analysis of comorbidities only hypertension was significantly associated with functional recovery. However, on multivariable analysis none of the analyzed comorbidities were associated with functional recovery. Conclusions: Recovery of function after partial nephrectomy depends primarily on parenchymal mass preservation and ischemia characteristics. Comorbidities failed to be associated with functional outcomes. Comorbidities can impact function, leading to surgery, and may influence long‐term functional stability. However, our data suggest that they do not influence short‐term recovery after partial nephrectomy.

Patterns of Long-term Cancer Survivorship Care in a National Cancer Institute-Designated Comprehensive Cancer Center.

Purpose: The majority of the cancer survivors in the United States are 5 or more years beyond their diagnosis. The follow-up care of these individuals remains a major concern for survivors and for the cancer care system. The purpose of this study was to characterize long-term cancer survivors’ visits at a National Cancer Institute-designated comprehensive cancer center. Materials and Methods: We abstracted electronic medical record data for 18,882 unique patients’ visits during 2010 to determine the distribution of the number of years of survival after the initial cancer diagnosis. We then reviewed 374 patient visits during a randomly selected week in April 2010 to determine whether patients were seen for treatment of a new diagnosis of cancer, a residual or recurrent cancer, for a second or secondary cancer, or for cancer survivorship care while not actively receiving treatment (other than adjuvant hormonal therapy). Results: In the 1-year group of 18,882 unique patients visits the percentage of patients who were <1, 1 to 5, 6 to 10, and >10 years postdiagnosis were 18.7%, 48.7%, 18.9%, and 13.8%, respectively. During the selected week, 74% of the total office visits were with patients who were being actively treated for a new cancer, relapse, or a second cancer, whereas 24% were not being seen for treatment of an active malignancy. The percentage of total office visits with patients who were <6, 6 to 10, or >10 years postdiagnosis and had completed their initial treatment were 21.4%, 3.7%, and 1%, respectively. Approximately 5% of oncology office visits were with cancer survivors who were 5 or more years postdiagnosis and not receiving treatment. Conclusions: In a database of over 18,000 unique patients who were seen at a major cancer center in 2010, approximately 68% were 5 or less and 32% were 6 or more years postdiagnosis. A review of the medical oncology notes in a random sample of cases of oncology visits demonstrated that approximately 5% of office visits were with long-term cancer survivors who were >5 years postdiagnosis and not receiving active treatment. Implications for Cancer Survivors: Cancer survivors often indicate a preference to receive long-term follow-up care from their oncologist. These findings suggest that long-term cancer survivorship care represents only a small component of care at a comprehensive cancer center and also that alternative models for long-term survivorship health care need to be considered.

Acute Kidney Injury after Partial Nephrectomy of Solitary Kidneys: Impact on Long-Term Stability of Renal Function

Purpose: Acute kidney injury often leads to chronic kidney disease in the general population. The long‐term functional impact of acute kidney injury observed after partial nephrectomy has not been adequately studied. Materials and Methods: From 2004 to 2014 necessary studies for analysis were available for 90 solitary kidneys managed by partial nephrectomy. Functional data at 4 time points included preoperative serum creatinine, peak postoperative serum creatinine, new baseline serum creatinine 3 to 12 months postoperatively and long‐term followup serum creatinine more than 12 months postoperatively. Adjusted acute kidney injury was defined by the ratio, observed peak postoperative serum creatinine/projected postoperative serum creatinine adjusted for parenchymal mass loss to reveal the true effect of ischemia. The long‐term change in renal function (the long‐term functional change ratio) was defined as the most recent glomerular filtration rate/the new baseline glomerular filtration rate. The relationship between the grade of the adjusted acute kidney injury and the long‐term functional change was assessed by Spearman correlation analysis and multivariable regression. Results: Median patient age was 64 years and median followup was 45 months. Median parenchymal mass preservation was 80%. Adjusted acute kidney injury occurred in 42% of patients, including grade 1 injury in 20 (22%) and grade 2/3 in 18 (20%). On univariable analysis the degree of the adjusted acute kidney injury did not correlate with the long‐term glomerular filtration rate change (p = 0.55). On multivariable analysis adjusted acute kidney injury was not associated with a long‐term functional change (p >0.05) while diabetes and warm ischemia were modestly associated with a long‐term functional decline (each p <0.05). Conclusions: Acute kidney injury after partial nephrectomy was not a significant or independent predictor of long‐term functional decline in our institutional cohort. A prospective study with larger sample sizes and longer followup is required to evaluate factors associated with long‐term nephron stability.