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Real-World Evidence

40: Surveillance is more common than kidney-sparing intervention for cT1 renal masses in patients with chronic kidney disease – analysis from the MUSIC-KIDNEY statewide collaborative

Background: Patients with chronic kidney disease (CKD) and renal masses represent a difficult to treat group, with high risk of renal function deterioration and surgical morbidity. A large body of literature highlights the importance of nephron sparing treatment in these patients, usually favoring partial nephrectomy (PN) over radical nephrectomy (RN). However, real world decision making is complex and patient-dependent, and little is known about management decisions in community-based practices. We describe treatment trends in patients with CKD and renal masses and the impact of treatment type on resulting GFR.

Methods: We reviewed the prospectively collected MUSIC-KIDNEY database for patients with cT1 renal masses (T1RM) from 2017 to 2022. Patients were categorized as having CKD if pre-existing GFR was < 60, or “no-CKD” for GFR>60. Post treatment GFR was recorded as the most recent GFR at least one month post treatment. Substantial GFR drop was defined as drop of >15% and to GFR < 45. Trends in treatment and GFR outcomes were compared between patients with or without CKD and between treatment categories of surveillance, ablation/SBRT, PN, and RN.

Results: Of 3036 patients evaluated for T1RM, 839 (27.6%) had pre-existing CKD. Similar proportions of patients underwent RN and ablation/SBRT in the CKD and no-CKD groups. Interestingly, PN was less common (17% vs. 34%) and surveillance more common (61% vs. 47%) in the CKD group. 102 of 431 patients (24%) with 6 month follow up GFR data had a substantial decline in GFR. Predictors of GFR decline included intervention (vs. surveillance) and pre-existing CKD.

Conclusions: Despite the long-held notion that patients with T1RM and CKD have an ‘imperative’ indication for kidney-sparing intervention, our study demonstrates that surveillance is the most commonly chosen treatment. Short term follow up demonstrates that active surveillance is a safe option in patients with CKD to avoid further GFR decline and peri-procedural morbidity.