Non-dialysis patients with advanced CKD diagnosed with renal malignancies grapple with the dual threat of renal failure and cancer progression. When  choosing between functional or oncologic risks, many patients will ask about renal transplantation. Discussions of  this option are complicated by statistical realities: According to UNOS, of  nearly 1 million solid organ transplants performed over the last 30 years, less  than 12% occurred in patients older  than 65. In 2018, approximately 25,000 of 130,000 potential kidney recipients were older than 65. Of these, only 18% received a transplant, with a median wait greater than 5 years.1 Unfortunately, overall survival rates in renal transplantation are lowest when ESRD is attributable to cancer.

These data suggest that in the RCC demographic, few patients are transplanted, wait times are long, and outcomes appear worse. In a small series from Mayo Clinic, only 15% of patients rendered surgically anephric for sporadic RCC underwent subsequent transplantation (median of 22 months). All transplant recipients were less than 70 years old, had cT1a tumors, and underwent a pre-nephrectomy transplant evaluation.2

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Such issues raise the question of how to manage active renal masses in non-dialysis patients with CKD stage 3b or worse when oncologic treatment poses a real risk to initiating renal replacement therapy (RRT) and a less than 1 in 5 chance of a subsequent transplant. Data support strong consideration for oncologic risk stratification using renal mass biopsy and an initial period of active surveillance (AS) for most localized RCCs in patients at high perioperative risks for RRT. These include a growing awareness of lead/length time biases, our burgeoning understanding of RCC biology, and the development of effective systemic therapies for advanced disease.

Judicious AS for patients with localized RCC with significant co-morbidities, including advanced CKD, is part of most major guidelines.  A growing literature regarding the safety of delayed management, comparative risks, survival estimates, and triggers for intervention are available.3 Ultimately, the outcome is an amalgam of biology, case selection, clinical experience, and patient preference, but a great pause should occur before rendering a patient in need of RRT from a localized renal mass. Comparing the Kaplan-Meier estimates for localized renal cancer under AS with those of patients on RRT, ask this question: Which survival curve would you rather be on?

References

  1. https://unos.org/data/transplant-trends/
  2. Boswell TC, Sharma V, Westerman ME, et al. Frequency and predictors of renal transplantation among patients rendered surgically anephric for sporadic renal cancer. Urology. 2019;126:134-139.
  3. McIntosh AG, Ristau BT, Ruth K, et al. Active surveillance for localized renal masses: Tumor growth, delayed intervention rates, and >5-yr clinical outcomes. Eur Urol. 2018;74:157-164.

Robert G. Uzzo, MD, FACS G. Willing “Wing” Pepper Chair in Cancer Research Professor and Chairman, Department of Surgery Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia

This article originally appeared on Renal and Urology News