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Effectiveness and Harms of Using Kidneys With Small Renal Tumors as a Source of Renal Transplantation
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The authors evaluated 19 studies (N = 109 patients) to assess the safety of kidney transplantation following back-table resection of small renal masses. Graft and overall survival rates were similar to those with conventional transplantation. A single local recurrence was reported, 9 years after transplantation. Particularly in the absence of deep hilar tumors, complications related to back-table resection were uncommon.
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Evidence suggests that transplantation of kidneys with small renal masses following partial nephrectomy is safe without compromising survival or functional outcomes for the recipient.
– Joshua Cohn, MD
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersCONTEXT
Kidney transplantation is the best treatment for patients with end-stage renal disease. Incidence of small renal masses (SRMs), which most frequently are renal cell carcinomas (RCCs), is highest in patients aged >60 yr. The increasing age of donors can lead to the diagnosis of a higher number of SRMs when assessing the patient for transplantation, and so can theoretically decrease the number of kidneys suitable for transplantation. Aiming to increase the pool of kidneys suitable for transplantation, a number of studies have reported their experience using kidneys with SRMs for transplantation.
OBJECTIVE
To systematically review all available evidence on the effectiveness and harm of using kidneys with SRMs as a source of transplantation.
EVIDENCE ACQUISITION
A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting outcomes of adult renal transplantation using kidneys with SRMs.
EVIDENCE SYNTHESIS
Nineteen studies enrolling 109 patients were included and synthesized narratively. The mean recipient age was 44.2 yr, and kidneys used were retrieved from living donors in 86% (94/109) of cases. Tumor excision was performed ex vivo in all cases except for two. The vast majority of excised tumors were RCCs (88/109 patients), and clear-cell subtype was most common. The mean tumor size was 2cm (range 0.5-6.0cm) and tumor grade was G1-G2 in 93% (75/81) of patients. With a mean follow-up of 39.9 mo, overall survival rates at 1, 3, and 5 yr were 97.7%, 95.4%, and 92%, respectively, and the mean graft survival rates 99.2%, 95%, and 95.6%, respectively. Only one local relapse occurred 9 yr after transplantation, which was managed conservatively. Functional outcomes, although infrequently reported, appear to be similar to those of conventional transplants, with 1.6% of these patients needing reoperation.
CONCLUSIONS
The current literature, although with low-level evidence, suggests that kidneys with excised SRMs are an acceptable source of transplantation without compromising oncological outcomes and with similar functional outcomes to other donor kidneys.
PATIENT SUMMARY
Renal transplantation using a kidney with a small renal mass does not appear to increase the risk of cancer recurrence and can be a good option for selected patients after appropriate counseling and allocation.
Additional Info
Disclosure statements are available on the authors' profiles:
Effectiveness and Harms of Using Kidneys With Small Renal Tumors From Deceased or Living Donors as a Source of Renal Transplantation: A Systematic Review
Eur Urol Focus 2018 Feb 09;[EPub Ahead of Print], V Hevia, R Hassan Zakri, C Fraser Taylor, HM Bruins, R Boissier, E Lledo, H Regele, K Budde, A Figueiredo, A Breda, CY Yuan, J OlsburghFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This is a well-done review of 19 low-level-of-evidence studies. It is important because 1) survival and quality of life are better with transplantation than dialysis for end stage renal disease patients who qualify for the waitlist; and 2) the chronic shortage of transplantable kidneys. Outcome data (overall survival, graft survival, recurrence-free survival, graft intervention-free survival, delayed graft function, and urinary leak) on 109 kidney transplants after excision of 108 T1a renal masses, 20 of which were benign and 88 of which were renal cell carcinomas, and one T1b mass, which was benign, were reported. The most common technique was back-table excision, confirmation of negative frozen section margins, renorrhaphy, and transplantation. The recurrence-free patient survival was 100% at 1, 3, and 5 years. Mean graft survivals at 1, 3, and 5 years were 99%, 95%, and 95%, respectively. The practice seemed to be safe, and the kidney transplants functioned well. The 2 reported cases of urinary leakage were associated with deep, endophytic hilar masses.
A basic question was answered: Should otherwise transplantable kidneys be discarded if they contain an excisable T1a renal cell carcinoma? No.
Caveat: Counseling and consent at the time of patient listing on the deceased donor waiting list, as practiced for high kidney donor profile index (KDPI) donors, is important, as is counseling and consent for both donor and recipient when the living renal donor has a T1a renal mass that is not a metastatic lesion.