Trends in management of the small renal mass in renal transplant recipient candidates: A multi-institutional survey analysis

Highlights

• A survey study to analyze treatment patterns to treat small renal masses of transplant candidates.

• General tendency is to perform radical nephrectomy and allow transplantation.

• Given sufficient evidence, transplant surgeons may consider active surveillance.

Abstract

Introduction

Patients with end-stage renal disease are under increased risk for renal cell carcinoma development, and radical nephrectomy is the preferred treatment in this setting. Owing to the increased surgical morbidity and mortality, active surveillance (AS) may be a valid option for treatment of small renal masses (SRM). As there is a lack of high-level evidence for treatment recommendations, we performed a survey analysis to analyze the treatment patterns of transplant surgeons.

Material and methods

A 21-question online survey designed to analyze the practice patterns to treat SRM in renal transplant recipient candidates was sent to active transplant centers in the United States. The list of recipients to whom the survey was distributed was obtained with permission from the American Society of Transplant Surgeons.

Results

We received 62 responses. All regions of United Network of Organ Sharing were represented. Radical nephrectomy was the preferred treatment (59%, n = 61), followed by AS (21.3%, n = 13), partial nephrectomy (14.8%, n = 9), and focal ablative therapy (4.9%, n = 3). Among the responders whose institutions did not allow AS, 77.4% indicated that if presented with long-term data showing safety of AS, they would perform immediate transplantation and monitor SRM. Responders were more likely to allow immediate transplantation after radical nephrectomy (77.4%), as opposed to partial nephrectomy (58.1%) and focal ablation (45.2%).

Conclusion

Though radical nephrectomy is the preferred treatment, most transplant surgeons would consider AS if long-term safety data were available.

Introduction

The number of patients diagnosed with end-stage renal disease (ESRD) has increased with time [1]. In the United States, more than 100,000 new patients are diagnosed every year [2]. Unless a suitable donor can be found, dialysis is the primary treatment, which has its inherent risks. Acquired renal cystic disease (ARCD) is associated with dialysis and is a predisposing factor to renal cell carcinoma (RCC) in 3% to 7% of patients [3], [4]. Incidence of ARCD increases as the time on dialysis increases [5]. Prevalence increases to 90% 5 years after the initiation of dialysis [4], [5]. In addition, ESRD and renal transplantation are shown to increase the risk of developing RCC regardless of ARCD [3], [6]. Incidence of RCC in native kidneys of hemodialysis patients is 0.5% to 4.2%, [5], [6] and incidence of kidney cancer increases 6-fold after transplantation [7].

There is a lack of high-level evidence to guide treatment of small renal masses (SRM) in the ESRD setting. Partial nephrectomy is the gold standard treatment for SRM (<4 cm) [8], [9]. As kidneys of patients with ESRD are nonfunctional, radical nephrectomy is preferred over partial nephrectomy and laparoscopic radical nephrectomy is a safe technique with excellent oncological outcome for organ-confined disease [9], [10]. However, radical nephrectomy is not without complications, and complications increase significantly in the ESRD setting. These risks include bleeding risk and blood transfusion, increased postoperative complications, prolonged hospitalization, and a 5-fold increased risk of in-hospital mortality [11]. These data beg the question of whether we can offer active surveillance (AS) to patients to avoid or delay surgical morbidity and mortality. We aimed to analyze the practice patterns of transplant surgeons regarding their practice of SRMs in renal transplant candidates.