The true risk of blood transfusion after nephrectomy for renal masses: a population-based study

Impact of perioperative blood transfusion on prognosis after nephrectomy in patients with renal cell carcinoma: A meta-analysis and systematic review

BACKGROUND

Perioperative blood transfusion (PBT) has been associated with worse prognosis in several malignancies. For renal cell carcinoma (RCC), the effect of PBT is still debated.

OBJECTIVE

To evaluate the impact of PBT on prognosis after nephrectomy in patients with RCC.

METHODS

This study is A systematic review and meta-analysis of published article data (PRISMA protocol) for literature related to PBT and RCC through extensive search of EMBASE, Medline via PubMed, Web of Science and Cochrane Library, language limited to English, with no time constraint until May 20, 2022. We pooled the results of multivariable cox regression analyses from each study, with subgroup analyses by dose and timing of transfusion. All analyses were done using Stata14.

RESULTS

A total of 12 studies involving 27,683 participants were included. Our meta-analysis pooled the results of multivariable cox regression analysis in each study, showing that PBT is associated with higher overall Mortality (OM; hazard ratio [HR] = 1.34, 1.23-1.44), cancer-specific mortality (CSM; HR = 1.35, 1.20-1.51), and disease recurrence (HR = 1.54, 1.18-1.89). when only patients with nonmetastatic RCC were included, PBT was still associated with higher OM (HR = 1.29, 1.11-1.47) and disease recurrence (HR = 1.58, 1.18-1.98), but the association with CSM (HR = 1.26, 0.99-1.52) was not statistically significant. In subgroup analysis by transfusion dose, small (1-2) units of PBT were not associated with CSM (HR = 1.84, 0.95-2.73), but large (≥3) units were associated with higher CSM (HR = 2.98, 1.74-4.22) and disease recurrence (HR = 1.99, 1.31-2.67). Each additional unit of PBT resulted in a higher CSM (HR = 1.07, 1.04-1.10). In subgroup analysis by transfusion timing, intraoperative transfusion was associated with higher CSM and disease recurrence, but postoperative transfusion was not.

CONCLUSIONS

PBT is associated with higher OM, CSM and disease recurrence. This adverse effect seems to be particularly significant in high-dose intraoperative transfusion. It is necessary to limit the overuse of PBT, especially high-dose intraoperative transfusion, in order to improve the prognosis of patients undergoing nephrectomy for RCC.

PADRES: a phase 2 clinical trial of neoadjuvant axitinib for complex partial nephrectomy

OBJECTIVE

To report the results of PADRES (Prior Axitinib as a Determinant of Outcome of Renal Surgery, NCT03438708), a study investigating neoadjuvant axitinib for tumours of high complexity with imperative indication for partial nephrectomy (PN).

METHODS

We conducted a single-arm phase II clinical trial of localized (cT1b-cT3M0) clear-cell renal cell carcinoma (RCC) patients with imperative indications for nephron preservation, where PN is a high-risk procedure due to complexity (RENAL score 10-12). Axitinib 5 mg was administered twice daily for 8 weeks with repeat imaging at completion, followed by surgery. The primary outcome was successful completion of planned PN following axitinib treatment. Secondary objectives included changes in tumour diameter, RENAL nephrometry score, renal function and Response Evaluation Criteria in Solid Tumours (RECIST) v1.1, and surgical complications.

RESULTS

Twenty-seven patients were enrolled (median age 69 years). Prior to therapy, twenty patients (74.0%) had ≥ clinical T3a staged tumours. Axitinib resulted in reductions in tumour diameter (7.5 vs 6.2 cm; P < 0.001) and RENAL score (11 vs 10; P < 0.001). Nine patients (33.3%) had partial response based on RECIST and nine (33.3%) were clinically downstaged. PN was performed in twenty patients (74.0%); twenty-five patients (96.2%) had negative margins. Six patients (22.2%) had Clavien III-IV complications. The median change in estimated glomerular filtration rate (preoperative to last follow-up) was 8.5 mL/min/1.73 m2 .

CONCLUSION

Neoadjuvant axitnib resulted in reductions in tumour size and complexity, enabling safe and feasible PN and functional preservation in patients with complex renal masses and imperative indication.

Impact of blood transfusion on survival after nephrectomy for localized or locally advanced renal cancer

OBJECTIVE

Several studies have reported blood transfusion were associated with a decrease of survival after oncological surgery. For kidney cancer, the effect of blood transfusion is still debated. The objective of this study was to determine the effect of blood transfusion after oncological nephrectomy on overall, specific and recurrence-free survival in a retrospective cohort of localized or locally advanced kidney cancer.

MATERIAL AND METHODS

We performed a monocentric retrospective analysis of all patients managed by surgery for localized or locally advanced renal cancer between January 2000 and December 2016. We compared overall and specific survival and recurrence-free survival between two groups: patients transfused and not transfused. Demographic, surgical and tumor characteristics were compared. Survival analyses were performed using univariate Cox regression and multivariate Cox proportional regression test.

RESULTS

We included 382 patients in this study: 320 (83.8%) were not transfused and 62 (16.2%) were transfused. Transfused patients were significantly older (P=0.001) and had a lower pre-operative hemoglobin level (P=0.008). Operative and oncological characteristics were also different between both groups. In univariate analysis, we showed that blood transfusion was associated with lower overall survival (P<0.001), specific survival (P<0.001), and recurrence-free survival (P<0.001). In multivariate analysis, we found that blood transfusion was not associated with overall survival, or specific survival, but it was associated with lower recurrence-free survival (HR: 1.967, CI95% [1.024-3.780], P=0.042).

CONCLUSIONS

Perioperative blood transfusion is an independent risk factor that increases tumor recurrence among patients treated with nephrectomy for renal cancer.

Is there an optimal trade-off between anaemia and red blood cell transfusion in surgical critically ill patients after oncologic surgery?

BACKGROUND AND OBJECTIVES

Equipoise remains on the optimal transfusion strategy in surgical oncologic patients. The primary objective of our study was to determine the impact of anaemia and red blood cells (RBCs) transfusion on severe postoperative complications in surgical oncologic critically ill patients.

MATERIALS AND METHODS

Retrospective single-centre study. Adults admitted to intensive care unit after major oncologic surgery were eligible. Analyses to determine the independent risk factors, including anaemia or RBC transfusion, for postoperative complications and/or hospital mortality were performed.

RESULTS

Of the 283 patients included, 246 patients (86.9%) had anaemia. Fifty-five patients (19·4%) were transfused. Patients exposed to moderate-to-severe anaemia or RBC transfusion had more often severe complications, especially acute kidney injury and infectious complications. Multivariate analysis found an independent association between moderate and severe anaemia and severe postoperative complications (moderate anaemia: OR 14·02 [2·52-264]; severe anaemia: OR 16·25 [2·62-318·5]; P < 0·05). Elderly, obese patients and patients operated from abdominal surgery appeared to be more vulnerable to anaemia than other patients. Transfusion was also an independent risk factor for postoperative complications (OR 4·19 [2·12-8·39]; P < 0·001). When considering moderate-to-severe anaemic patients, RBC transfusion was no longer associated with postoperative complications.

CONCLUSIONS

Anaemia was associated with severe postoperative complications, and this association was stronger in elderly, obese patients and after abdominal surgery. RBC transfusion also negatively impacts on patients' prognosis. However, this association was not found in case of moderate-to-severe anaemia exposure (haemoglobin < 10 g/dl).

Perioperative Blood Transfusion Is a Predictor of Acute and Chronic Renal Function Deterioration after Partial and Radical Nephrectomy for Renal Cell Carcinoma

INTRODUCTION

The aim was to evaluate the impact of perioperative blood transfusions (PBTs) on renal function after surgery for renal cell carcinoma (RCC).

METHODS

Consecutive patients with RCC who underwent partial nephrectomy or radical nephrectomy between 2005 and 2015 at a tertiary care center were included. Minimum follow-up period was 6 months. A PBT was defined as the transfusion of packed erythrocyte concentrate (EC) within 7 days before until 30 days after surgery. The multivariable analyses were carried out by Cox regression.

RESULTS

The overall cohort included 851 patients, of whom 93 (10.9%) received a PBT. The median follow-up was 46 months (range 28-72). In case of a PBT, a median of 2 EC was transfused. PBT patients were older and had a poorer performance status and more comorbidities as well as locally more advanced or metastatic tumors. In the multivariable analyses, PBT was an independent prognostic factor for acute as well as chronic renal impairment (hazard ratio (HR) 2.72, 95% confidence interval (95% CI) 1.45-5.10, p = 0.002 and HR 2.23, 95% CI 1.26-3.70, p = 0.007).

CONCLUSION

PBT is associated with acute and chronic deterioration of kidney function after surgery for RCC. Thus, it may be used to identify patients requiring close nephrological monitoring.

Impact of perioperative blood transfusions on clinical outcomes in patients undergoing surgery for major urologic malignancies

The association between allogeneic perioperative blood transfusion (PBT) and decreased survival among patients undergoing various oncological surgeries has been established in various malignant diseases, including colorectal, thoracic and hepatocellular cancer. However, when focusing on urologic tumors, the significance of PBT and its adverse effect remains debatable, mainly due to inconsistency between studies. Nevertheless, the rate of PBT remains high and may reach up to 62% in patients undergoing major urologic surgeries. Hence, the relatively high rate of PBT among related operations, along with the increasing prevalence of several urologic tumors, give this topic great significance in clinical practice. Indeed, recent retrospective studies, followed by systematic reviews in both prostate and bladder cancer surgery have supported the association that has been demonstrated in several malignancies, while other major urologic malignancies, including renal cell carcinoma and upper tract urothelial carcinoma, have also been addressed retrospectively. It is only a matter of time before the data will be sufficient for qualitative systematic review/qualitative evidence synthesis. In the current study, we performed a literature review to define the association between PBT and the oncological outcomes in patients who undergo surgery for major urologic malignancies. We believe that the current review of the literature will increase awareness of the importance and relevance of this issue, as well as highlight the need for evidence-based standards for blood transfusion as well as more controlled transfusion thresholds.

A conceptual framework for evaluating data suitability for observational studies

Objective

To contribute a conceptual framework for evaluating data suitability to satisfy the research needs of observational studies.

Materials and Methods

Suitability considerations were derived from a systematic literature review on researchers’ common data needs in observational studies and a scoping review on frequent clinical database design considerations, and were harmonized to construct a suitability conceptual framework using a bottom-up approach. The relationships among the suitability categories are explored from the perspective of 4 facets of data: intrinsic, contextual, representational, and accessible. A web-based national survey of domain experts was conducted to validate the framework.

Results

Data suitability for observational studies hinges on the following key categories: Explicitness of Policy and Data Governance, Relevance, Availability of Descriptive Metadata and Provenance Documentation, Usability, and Quality. We describe 16 measures and 33 sub-measures. The survey uncovered the relevance of all categories, with a 5-point Likert importance score of 3.9 ± 1.0 for Explicitness of Policy and Data Governance, 4.1 ± 1.0 for Relevance, 3.9 ± 0.9 for Availability of Descriptive Metadata and Provenance Documentation, 4.2 ± 1.0 for Usability, and 4.0 ± 0.9 for Quality.

Conclusions

The suitability framework evaluates a clinical data source’s fitness for research use. Its construction reflects both researchers’ points of view and data custodians’ design features. The feedback from domain experts rated Usability, Relevance, and Quality categories as the most important considerations.

Perioperative Allogenic Blood Transfusion in Renal Cell Carcinoma: Risk Factors and Effect on Long-term Outcomes

BACKGROUND

We sought to create a preoperative model to predict the risk of perioperative blood transfusion (PBT) in patients with renal cell carcinoma (RCC) undergoing nephrectomy and to evaluate the effect of PBT on long-term outcomes.

PATIENTS AND METHODS

The present retrospective study included 648 consecutive patients who had undergone radical or partial nephrectomy for RCC at a single institution. The risk factors for PBT were analyzed using logistic regression analysis. Cox proportional hazards models addressed the effect of PBT on overall and RCC-specific mortality.

RESULTS

A total of 62 patients (10%) received a median of 2 red blood cell units (interquartile range, 2-3; range 1-20). On multivariable logistic regression analysis, 2 preoperative factors were independently associated with receipt of PBT: preoperative anemia (odds ratio, 6.28; P < .001) and open surgery (odds ratio, 3.40; P < .001). The risk of receiving PBT was high with both risk factors present (34%), intermediate with 1 risk factor present (7%-12%), and low with 0 risk factors present (2%). Within a median follow-up period of 63 months (interquartile range, 32-91), 108 patients (17%) had died of RCC and 177 (27%) had died of any cause. In the multivariable Cox models, PBT remained independently associated with overall mortality (hazard ratio [HR], 1.86; P = .004) and RCC-specific mortality (HR, 1.79; P = .007). A dose-dependent association of PBT with RCC-specific mortality was observed (HR, 1.14; P = .01).

CONCLUSION

In patients undergoing surgery for RCC, PBT was associated with adverse overall and RCC-specific mortality. Patients with preoperative anemia and those scheduled to undergo open surgery are at an increased risk of PBT and could be candidates for perioperative optimization techniques.

Patient and disease factors predictive of adverse perioperative outcomes after nephrectomy

INTRODUCTION

The aim of this study was to determine the patient and disease factors predictive of adverse perioperative outcomes after nephrectomy using the British Association of Urological Surgeons (BAUS) audit database.

METHODS

All nephrectomies entered on the BAUS database for the year 2012 were included and ten patient or disease factors were selected for analysis. Logistic regression was used to calculate the area under the receiver operating characteristic curve (AUC) (0.5 = no better than chance, 1.0 = perfect prediction) for each variable and 500 bootstrap samples were used to determine variable selection.

RESULTS

Data were captured for 6,031 nephrectomies in 2012. World Health Organization performance status (WHO-PS) (AUC: 0.733) and anaemia (AUC: 0.696) were the most significant predictors of 30-day mortality in univariate analysis. WHO-PS (AUC: 0.626) and anaemia (AUC: 0.590) also predicted complications classified as Clavien-Dindo grades III-V. Anaemia (AUC: 0.722) and clinical T stage (AUC: 0.713) predicted need for transfusion.

CONCLUSIONS

Adverse perioperative outcomes after nephrectomy are predicted by clinical presentation with haematuria, poor WHO-PS and higher TNM (tumour, lymph nodes, metastasis) stage. This study used surgeon collected data as opposed to an administrative database, which may have advantages in terms of accuracy and breadth of data fields. These data form a basis for preoperative patient counselling and informed consent for nephrectomy. They can also be used as a standard against which surgeons and hospitals can compare their own results.

Incidence and risk factors for 30-day readmission in patients undergoing nephrectomy procedures: a contemporary analysis of 5276 cases from the National Surgical Quality Improvement Program database

OBJECTIVE

To explore factors associated with readmission after nephrectomy procedures using a large national database.

MATERIALS AND METHODS

A national surgical outcomes database, the American College of Surgeon-National Surgical Quality Improvement Program registry, was queried for data on all patients undergoing open partial nephrectomy (OPN), minimally invasive (laparoscopic + robotic) partial nephrectomy (MIPN), and minimally invasive radical nephrectomy (MIRN) in 2011 and 2012. Patients undergoing these procedures were identified using the Current Procedural Terminology codes. The primary outcome was unplanned 30-day hospital readmission. A multivariate logistic regression model was constructed to assess for factors independently associated with the primary outcome.

RESULTS

Overall, 5276 cases were identified and included in the analysis: 1411 OPN (26.7%), 2210 MIPN (41.8%), and 1655 MIRN (31.3%). Overall, the 30-day readmission rate was 5.9% (7.8% for OPN, 4.5% for MIPN, and 6.1% for MIRN). On multivariate analysis, the odds for 30-day readmission for MIPN was approximately 70% that of OPN (P = .012). The odds for 30-day readmission for 2012 was about 80% of that of 2011 (P <.001). History of steroid use and of bleeding disorder and occurrence of postoperative transfusion increase the odds of readmission by approximately 2 (P = .005, P = .038, and P <.001, respectively). A postoperative urinary infection increased the odds of readmission by 5.5 (P <.001).

CONCLUSION

Contemporary 30-day readmission rates after nephrectomy procedures are influenced by specific patients' characteristics as well as postoperative adverse events. Moreover, contemporary MIPN seems to carry lower odds of readmission than OPN. It remains to be determined to what extent these findings are influenced by the expanding role of robotic technology.

The impact of perioperative blood transfusion on survival after nephrectomy for non-metastatic renal cell carcinoma (RCC)

OBJECTIVE

To evaluate the association of perioperative blood transfusion (PBT) with survival after nephrectomy.

PATIENTS AND METHODS

We identified 2318 patients who underwent partial or radical nephrectomy at Mayo Clinic between 1990 and 2006. PBT was defined as transfusion of allogenic red blood cells during surgery or postoperative hospitalisation. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards regression models were used to evaluate the association of PBT with outcome.

RESULTS

In all, 498 patients (21%) received a PBT. The median (interquartile range) number of units transfused was 3 (2, 5). Patients receiving a PBT were significantly older at surgery (P < 0.001), more likely to be female (P < 0.001), with more frequent symptomatic presentation (P < 0.001), worse Eastern Cooperative Oncology Group performance status (P < 0.001), and more frequent adverse pathological features, such as high nuclear grade (P < 0.001), locally-advanced tumour stage (P < 0.001) and lymph node invasion (P < 0.001). The median follow-up was 9.1 years. Receipt of a PBT was associated with adverse 5-year cancer-specific (68% vs 92%; P < 0.001) and overall (56% vs 82%; P < 0.001) survival. On multivariate analyses, PBT remained associated with higher risk of death from any cause (hazard ratio [HR] 1.23; P = 0.02). Among patients who received a PBT, an increasing number of units transfused was independently associated with increased all-cause mortality (HR 1.08; P = 0.001).

CONCLUSION

PBT is associated with a significantly increased risk of mortality after nephrectomy. While external validation is needed, continued efforts to minimise the use of blood products in these patients are warranted.