Why Radical vs Partial Nephrectomy Matters in Patients With Preexisting Renal Dysfunction: Exploring Chronic Kidney Disease Progression by Stage

Abstract

Introduction: Nephrectomy remains the curative standard for localized renal cell carcinoma. Partial nephrectomy (PN) is generally favored over radical nephrectomy (RN) for patients with chronic kidney disease (CKD) stage 3a or worse to preserve renal function. However, evidence stratifying CKD progression risk by preoperative stage is limited. We aimed to compare stage-specific postoperative CKD progression by nephrectomy type.

Methods: We reviewed prospectively maintained nephrectomy databases from 2 academic institutions (2000-2024) for adults with localized renal cell carcinoma (T1-3N0M0), preoperative CKD2-4, and available demographic and clinical data. CKD stage was classified using CKD-Epidemiology (CKD-EPI) 2009 and 2021 equations. Multivariable logistic regression adjusted for age, gender, obesity, race, and nephrectomy type evaluated CKD stage progression within 2 to 6 months postoperatively. Ratio-of-odds analysis quantified relative deterioration risk by stage.

Results: Using CKD-EPI 2009 and 2021, 1257 and 1180 patients met criteria, respectively; ∼69% underwent RN. RN was associated with significantly higher odds of 1-stage deterioration across all CKD stages except CKD4 and 2-stage deterioration in CKD2 and CKD3a patients. No significant end-stage renal disease risk difference was observed in any stage. Ratio-of-odds analysis showed CKD2 patients had 2-fold to 3-fold higher deterioration risk than CKD3a following RN.

Conclusions: RN confers greater risk of CKD progression vs PN across preoperative CKD stages except CKD4, independent of estimated glomerular filtration rate equation. CKD2 patients demonstrated the highest relative deterioration risk. These findings suggest nephrectomy type may disproportionately affect patients with greater renal reserve, supporting broader use of PN above current guideline thresholds.

Keywords: ESRD; chronic kidney disease; nephrectomy; progression; risk.