Comparative analysis of mortality and progression to end-stage renal disease between surgically induced-chronic kidney disease (CKD) versus medical CKD

Abstract

Purpose: To analyze whether there is a difference in progression to end-stage renal disease (ESRD) and survival rate between surgically-induced chronic kidney disease (CKD-S) and medically-induced chronic kidney disease (CKD-M). Methods: Two different cohort studies were conducted. The first study was a multicenter hospital-based cohort, and patients who underwent partial or radical nephrectomy for renal cell carcinoma (RCC) without preoperative CKD were included in the CKD-S group. Patients enrolled in the Korean cohort study for Outcomes in Patients with Chronic Kidney Disease (KNOW-CKD) were included in the CKD-M group. The second study was a population-based cohort study using medical records, and estimated glomerular filtration rates in health checkups were extracted from the Korean National Health Insurance Service database. The primary outcome was progression to ESRD, defined as dialysis or kidney transplantation. The secondary outcome was all-cause mortality. Results: In the first study, patients with CKD-M were at higher risk of progression to ESRD (hazard ratio [HR]: 9.89, 95% confidence interval [CI]: 4.67–20.92, p<0.001) and overall death (HR: 1.32, 95% CI: 0.79–2.19, p=0.288). In the Kaplan-Meier analysis, the incidence of ESRD was significantly higher in the CKD-M group. In a subgroup analysis of those who were followed up for >5 years after adjusting for age, sex, body mass index, hypertension, and diabetes, the odds ratio of progression to ESRD or a 50% decrease in GFR within 5 years was significantly higher in the CKD-M group. In the second study, in the whole matched cohort without cardiovascular disease (CVD) history, patients with CKD-M were at higher risk of progression to ESRD (HR: 1.895, 95% CI: 1.044–3.442, p=0.0357) and CVD (HR: 1.167, 95% CI: 1.057–1.289, p=0.0023) than those with CKD-S. Patients with CKD-M were at lower risk of overall death; however, this observation was not statistically significant (HR: 0.922, 95% CI: 0.718–1.185, p=0.5268). Among patients with CKD grade ≥3 in the whole cohort, including CVD history, the CKD-M group was at significantly higher risk of progression to ESRD (HR: 2.208, 95% CI: 1.474–3.306, p=0.0001), CVD (HR: 1.318, 95% CI: 1.198–1.451, p<0.0001), and overall mortality (HR: 1.497, 95% CI: 1.208–1.856, p=0.0002). Conclusion: Patients with CKD-S appear to have a lower risk of developing ESRD than those with CKD-M in this study. Regarding mortality and progression to ESRD, it might not be accurate to conceive CKD-S and CKD-M as being on the same CKD spectrum.

수술군은 내과군보다 만성신장병으로 진행할 위험도가 두 연구 모두에서 유의하게 낮았다. 또한 수술군은 내과군보다 사망 위험도가 두 연구의 결과를 종합하였을 때 낮은 경향을 보였다. 만성신장병이 수술로 인해 생긴 경우와 내과적으로 생긴 경우는 서로 동일하지 않은 질환 스펙트럼에 있는 것으로 보인다. 특히 당뇨가 있는 환자는 수술 후 신기능 저하가 발생하면 만성신부전 및 사망의 위험도가 유의하게 높으므로 신기능 관리에 각별한 주의가 요구된다.