Next Article in Journal
Pro/Antioxidant State as a Potential Biomarker of Schizophrenia
Previous Article in Journal
Feasibility and Outcomes of “No-Look No-Touch” Laparoscopic Radical Trachelectomy for Early-Stage Cervical Cancer
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JCM
Volume 10
Issue 18
10.3390/jcm10184155
jcm-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

Estimated Glomerular Filtration Rate as a Prognostic Factor in Urothelial Carcinoma of the Upper Urinary Tract: A Systematic Review and Meta-Analysis

by
Min Hyuk Kim
,
Hyeong Dong Yuk
,
Chang Wook Jeong
,
Cheol Kwak
,
Hyeon Hoe Kim
and
Ja Hyeon Ku
*
Department of Urology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Korea
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2021, 10(18), 4155; https://doi.org/10.3390/jcm10184155
Submission received: 3 August 2021 / Revised: 3 September 2021 / Accepted: 14 September 2021 / Published: 15 September 2021
(This article belongs to the Section Nephrology & Urology)
Browse Figures
Review Reports Versions Notes

Abstract

:
Preoperative renal function is associated with worse outcomes in patients undergoing radical nephroureterectomy (RNU). The purpose of this systemic review and meta-analysis was to determine the association of preoperative renal function with oncological outcome in patients who underwent RNU. We searched articles published up to March 2021 in PubMed, Scopus, and Embase by combining “urothelial carcinoma”, “radical nephroureterectomy”, and “estimated glomerular filtration rate”. We also manually screened the reference list for publications following general guidelines recommended by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. The relationship between preoperative renal function and survival was expressed as overall survival (OS), progression-free survival (PFS), and cancer-specific survival (CSS). This review and meta-analysis included 13 studies involving a total of 4668 patients who received RNU. Pooled analysis showed significant negative association of preoperative renal function with PFS (HR: 1.51, 95% CI: 1.23–1.80, p < 0.00001), CSS (HR: 1.63, 95% CI: 1.38–1.92, p < 0.00001), and OS (HR: 1.22, 95% CI: 1.10–1.35, p < 0.00001). Patients with upper tract urothelial carcinoma (UTUC) who received RNU showed a significant negative association of preoperative renal function with survival.

1. Introduction

Tumors originating in urothelial cells, including ureter to renal pelvis, are known as upper tract urothelial carcinomas (UTUCs). UTUCs are rare malignant tumors that account for approximately 5–10% of all urothelial cancers [1,2,3]. Radical nephroureterectomy (RNU) with bladder cuffing represents the ultimate treatment for highly recurrent UTUC [4,5]. In previous studies, the classification of five-year cancer-specific survival (CSS) was based on pathologic stages. The 5-year CSS exceeded 90% when the final pathological result was pT1 (non-muscle invasive cancer) or less. However, the 5-year CSS decreased to 40% when the pathological result was pT3 or higher [6]. This finding suggests that RNU is sufficient for organ-confined early-stage UTUC, whereas RNU alone is insufficient for non-organ confined advanced UTUC with non-organ confined or lymph node metastasis. Complete lymph node dissection along with RNU can increase CSS in patients with UTUCs (pT3 or higher) [7,8,9,10]. Other studies reported that adjuvant chemotherapy with locally advanced UTUC (pT3N0/Nx, pT4N0/Nx, or pTanyN+) can effectively increase CSS [11]. Based on the findings of previous studies, locally advanced UTUCs are an indication for lymph node dissection and adjuvant chemotherapy.
Several prognostic factors for UTUC have been reported. Postoperative pathological parameters such as pathologic tumor stage (pT), lympho-vascular invasion (LVI), tumor grade, tumor necrosis, lymph node (LN) involvement, surgical margin, and histological variants are strong prognostic factors. Preoperative prognostic factors include the presence of hydronephrosis, serum CRP, tumor size, tumor location, history of previous bladder cancer, age, Eastern Cooperative Oncology Group performance status (ECOG PS), and chronic kidney disease (CKD) [12,13,14,15,16,17,18,19,20,21]. However, most of the studies reporting various prognostic factors were retrospective in design.
CKD is a common disease diagnosed in the elderly population. It is associated with malignancies of kidney and ureter [22,23]. The underlying treatment for UTUC is radical resection of the kidney, leaving the patient with a unilateral kidney for survival after surgery. As the unilateral kidney after the surgery needs to perform the function of both kidneys, the patient’s renal function might be reduced compared with the level before the surgery, which could result in CKD and affect survival [24,25] Renal function is particularly important in patients with locally advanced UTUC because of the need for adjuvant chemotherapy after surgery. Although many studies have shown that CKD is a significant preoperative prognostic factor in UTUC, most of these studies are limited by their retrospective format. Therefore, the objective of this study was to analyze the association of preoperative renal function with postoperative survival using a systematic review and meta-analysis.

2. Materials and Methods

This systematic review and meta-analysis was conducted and reported in accordance with the general guidelines recommended by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement [26]. We reviewed studies involving participants who underwent radical nephrectomy for UTUC, including open laparoscopic and robotic surgical interventions.

2.1. Data Sources and Search Strategy

The PRISMA flow chart is shown in Figure 1. We searched PubMed, Scopus, and Embase for related articles published before March 2021. The following search terms and their combinations were used: “urothelial carcinoma”, “radical nephroureterectomy”, and “estimated glomerular filtration rate”. We also manually screened the reference lists of publications to identify potentially relevant studies for analysis.

2.2. Inclusion and Exclusion Criteria

We used strict inclusion and exclusion criteria to limit the heterogeneity of the entire study. If the study met the following including criteria, it was eligible for additional evaluation: (1) patients diagnosed with urothelial carcinoma via pathological testing; (2) determination of relationship between preoperative renal function and prognosis; and (3) studies describing the hazard ratio (HR) and 95% confidence interval (CI) using multivariate survival analysis.
The exclusion criteria were: (1) letters, comments, case reports, reviews, and conference abstracts with limited data; (2) publications in languages other than English; (3) studies performed using animals or cell lines; and (4) duplicate articles and articles with duplicate data. If the same patient population was evaluated in several studies, only the latest or the largest study was included in the analysis. Studies that did not report adjusted HR using multivariate analysis were excluded because of uncertain accuracy of HR without multivariate analysis. For studies that leveraged both multivariate and univariate analyses to estimate clinical outcomes, results of the multivariate analysis were used to calculate HR and CI. Each study was independently screened by two reviewers (M.H.K. and J.H.K.) to determine compliance with the selection criteria. Any disagreement was resolved by consensus. Finally, 13 papers [7,11,22,27,28,29,30,31,32,33,34,35,36] were included in this study.

2.3. Data Extraction

Two investigators (H.D.Y. and C.W.J.) reviewed each eligible article individually and extracted information from all publications that met the inclusion criteria. Information was retrieved based on the Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK) involving prognostic markers. The data table was configured to extract all relevant data contained in each study text, table, or figure. Disagreement was resolved through discussion.

2.4. Quality Assessments

Methodological quality of each study was evaluated independently by three reviewers (M.H.K., C.K. and H.H.K.) using the Newcastle–Ottawa scale (NOS) including cohort studies only (Supplementary Materials Table S1). A maximum score of 1 was assigned to each item and a maximum score of 2 was allowed only for comparability. Therefore, the final quality score varied from 0 (the lowest) to 9 (the highest), and a total score of 0–5 was considered low, 6–7 was considered intermediate, and 8–9 was considered high quality.

2.5. Definition of Survival

Definition 1.
Survival is defined as follows. Cancer-specific survival (CSS) is the period of survival until death from cancer after surgery, and progression-free survival (PFS) is the period of recurrence of cancer at the surgical site, metastasis to nearby lymph nodes, and metastasis to distant sites. Overall survival (OS) represents the survival period after surgery.

2.6. Statistical Analysis

Survival data were compiled based on the time-to-event occurrence HR for operating measurements. The HRs and 95% CIs were calculated using a random-effects model. Forest plots were used to estimate the effect of eGFR on patient survival and disease progression. A statistical test of heterogeneity was performed based on the Q-test and I2 test to assess heterogeneity during the study [37]. A p-value > 0.05 and an I2 < 50% were considered non-heterogeneous. Potential publication bias was assessed through visual inspection of the funnel plot. Statistical significance was defined at the 0.05 level. All statistical analyses were performed using RevMan 5.4.1 software (Cochrane Collaboration, Cochranehagen, London, UK).

3. Results

Individual characteristics of 13 studies are presented in Table 1. The recruitment period was from 1991 to 2017. The number of patients included in these studies ranged between 70 and 666, with a total of 4668 patients. All 13 were retrospective studies. Of them, 11, 2, and 11 studies mentioned inclusion/exclusion criteria, definition of survival, and definition of eGFR, respectively.
Table 2 shows patient characteristics reported in each study. Median age ranged from 67 to 74 years. Three studies did not indicate age. Nine studies described a surgical approach. An open approach was used for 2031 cases and a laparoscopic approach was adopted for 2393 cases. The median follow-up period ranged from 16 to 65 months.
Tumor and pathologic characteristics are listed in Table 3 and Table 4, respectively. Ten studies reported tumor location. The renal pelvis harbored 1830 tumors and the ureter carried 1783 tumors. In nine studies, a total of 656 people received adjuvant chemotherapy. In 11 studies, tumor grade was low in 1335 (31%) cases and high in 2950 (69%) cases. The pathologic T stage was described in nine studies, including 2381 (60%) below pathologic T2 and 1577 (40%) higher than T3.
Table 5 presents results of multivariate analyses using the Cox proportional hazards model. Survival analysis was expressed as overall survival (OS), progression-free survival (PFS), or cancer-specific survival (CSS). The standard of eGFR was set at 30 mL/min/1.73 m2 in one study, 50 mL/min/1.73 m2 in two studies, and 60 mL/min/1.73 m2 in the remaining studies.
Figure 2 presents a forest plot and a funnel plot to demonstrate PFS according to preoperative renal function. Eight studies were included. Five studies showed significant positive association between PFS and preoperative renal function (adjusted HR: 1.51; 95% CI: 1.23–1.80, p < 0.00001). The funnel plot was relatively symmetrical, showing no evidence of significant publication bias.
Nine studies showed a relationship between CSS and preoperative renal function. The forest plot and funnel plot are shown in Figure 3. All but one study showed a positive association between CSS and preoperative renal function. Six studies showed a significant positive association between CSS and preoperative renal function (adjusted HR: 1.63, 95% CI: 1.38–1.92, p < 0.00001). The funnel plot was relatively symmetrical, without strong evidence for publication bias.
Seven studies showed a relationship between OS and preoperative renal function. Forest plots and funnel plots are shown in Figure 4. All but one study showed a positive association between OS and preoperative renal function. Three studies showed a significant positive association between OS and preoperative renal function (adjusted HR: 1.22, 95% CI: 1.10–1.35, p < 0.00001). We could not find a strong evidence for publication bias based on the funnel plot.

4. Discussion

This study investigated whether renal function of patients with UTUC before RNU was associated with survival rate. Thirteen studies were included. The total number of patients was 4668. All patients were diagnosed with UTUC and, therefore, underwent RNU. Each study expressed the survival rate as CSS, PFS, or OS. The final meta-analysis showed that preoperative renal function was related to postoperative survival rate.
Ito et al. [7] analyzed 70 patients with N0M0 UTUC who underwent unilateral RNU between 1999 and 2012. The survival rate was expressed as a 3-year extraurothelial recurrence-free survival rate (EURFS). In the multivariate Cox proportional hazards model, the EURFS had a worse outcome in patients with a preoperative eGFR less than 60 mL/min/1.73 m2 (HR: 6.579, 95% CI: 1.934–22.222, p = 0.0026). Yeh et al. [35] investigated the postoperative prognosis according to the presence of preoperative hydronephrosis and flank pain in 472 UTUC patients who underwent RNU in a single medical center from 1991 to 2013. The survival rate was expressed as 5-year CSS and 5-year OS using the Kaplan–Meier method. The eGFR was set at 60 mL/min/1.73 m2. Those with preoperative hydronephrosis and flank pain had worse outcomes of 5-year CSS and 5-year OS, respectively. Since preoperative hydronephrosis and flank pain were associated with preoperative renal function, patients with eGFR less than 60 mL/min/1.73 m2 before surgery had worse outcomes of 5-year CSS (HR: 1.691, 95% CI: 1.071–2.669, p = 0.024) and 5-year OS (HR: 1.577, 95% CI: 1.045–2.382, p = 0.030). Ehdaie et al. [38] developed a model to predict the prognosis of 253 patients who underwent RNU for UTUC between 1995 and 2008. A multivariable Cox regression model was used and eGFR was set as a continuous variable. Survival rates were expressed as 5-year CSS and 5-year PFS. The higher the preoperative eGFR, the better was the 5-year PFS (HR: 0.73, 95% CI: 0.61–0.88, p < 0.001) and 5-year CSS (HR: 0.74, 95% CI: 0.61–0.90, p = 0.002).
These preceding studies showed that preoperative renal function was positively correlated with CSS, PFS, and OS of patients with UTUC. However, Xylinas et al. [28] showed no association between preoperative renal function and survival rate of patients with UTUC who underwent RNU. Xylinas et al. investigated 781 patients with UTUC treated with RNU from 1994 to 2007 at seven different centers. The preoperative eGFR criterion was set at 60 mL/min/1.73 m2, and the postoperative eGFR criterion was set at 45 mL/min/1.73 m2. Univariable and multivariable Cox regression models were used. Neither preoperative nor postoperative eGFR was associated with 5-year CSS, PFS, or OS. In our systematic review and meta-analysis, eight studies demonstrated a relationship between PFS and preoperative eGFR (adjusted HR: 1.51, 95% CI: 1.23–1.80, p < 0.00001). In five studies, PFS and preoperative eGFR showed a significant positive correlation. Although one study showed a positive correlation and two studies showed a negative correlation, all three studies showed no significant correlations. Nine studies showed a relationship between CSS and preoperative eGFR. Although one study showed a negative correlation between CSS and preoperative eGFR and two studies showed a positive correlation, none of them showed statistically significant correlation between CSS and preoperative eGFR. The remaining six studies showed a significant positive relationship between the two (adjusted HR: 1.63, 95% CI: 1.38–1.92, p < 0.00001). Seven studies showed a relationship between OS and preoperative eGFR. Although one study showed a negative relationship, the correlation was not significant. Six studies showed a positive relationship between OS and preoperative eGFR. However, only three studies showed significant correlation between the two variables (adjusted HR: 1.22, 95% CI, 1.10–1.35, p < 0.00001). Results of this study confirmed that the preoperative renal function of patients was closely related to their survival rate after RNU.
Several previous studies have shown that renal function decreases after kidney surgery [28,39,40]. Although patients who underwent radical nephrectomy had severe renal impairment more than those who underwent partial nephrectomy, the rate of CKD was increased postoperatively in patients with partial nephrectomy [41]. In addition, UTUC patients who underwent radical nephrectomy had significantly higher serum creatinine increase and higher rates of ESRD hemodialysis than those of RCC patients (HR: 2.9, 95% CI: 1.88–4.49, p < 0.001) [39]. Some studies have shown that patients with CKD or ESRD exhibited a lower survival rate than that of those with normal renal function [24,25]. If UTUC patients manifest reduced preoperative renal function, they carry a high probability of developing CKD or ESRD due to their decreased renal function after radical nephrectomy-based RNU. Therefore, it can be inferred that they will have poor outcomes such as disease prognosis and survival rate.
Patients with non-organ-confined or lymph node metastasis undergoing UTUC require adjuvant chemotherapy because it is impossible to perform surgical treatment. Adjuvant chemotherapy for UTUC basically entails a combination of gemcitabine and cisplatin [42,43]. Cisplatin-induced nephrotoxicity is well known [44,45]. When cisplatin is absorbed into renal tubular cells, it can trigger an inflammatory response via multiple signaling pathways, leading to histological damage. Cisplatin also affects renal vessels and causes ischemic damage [46]. Therefore, patients with reduced renal function cannot use cisplatin-based chemotherapy and, thus, exhibit a worse survival rate.
Our systematic review and meta-analysis study has several limitations. First, 10 out of 13 studies involved Asians including five from Japan, three from Taiwan, and one each from Korea and China [7,22,27,29,30,32,33,34,35,36]. The remaining three papers included two from a multinational study and one from the United States [11,28,31]. The number of patients included 3343 Asians, 245 Americans, and 1080 patients from multiple nations. Thus, Asians accounted for at least 71% of all subjects. Since Asians were included in the study performed in the United States and different nations, it limited the evaluation of other ethnic groups. Second, all 13 papers included in this study were retrospective studies. However, most of these studies had an adequate sample size and a NOS quality score of 6 or higher. Finally, there was heterogeneity between papers. The I2 value indicating heterogeneity exceeded 50% (PFS, 64%; CSS, 56%). Thus, the results of this systematic review and meta-analysis require careful interpretation.
In conclusion, this systematic review and meta-analysis revealed that patients with decreased eGFR before surgery manifested poor PFS, CSS, and OS after RNU. However, all studies included in this meta-analysis were retrospective in nature. Thus, a large-scale prospective study is needed in the future.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/jcm10184155/s1, Table S1: Assessment of quality of the non-randomized controlled trials (RCTs) using the Newcastle–Ottawa scale for cohort studies.

Author Contributions

Conceptualization, J.H.K. and M.H.K.; methodology, J.H.K.; software, J.H.K.; validation, H.D.Y. and C.W.J.; formal analysis, J.H.K. and M.H.K.; investigation, J.H.K., M.H.K., H.D.Y. and C.W.J.; resources, J.H.K.; data curation, M.H.K., C.K. and H.H.K.; writing—original draft preparation, M.H.K.; writing—review and editing, M.H.K.; visualization, J.H.K.; supervision, J.H.K. All authors have read and agreed to the published version of the manuscript.

Funding

This study received no external funding.

Institutional Review Board Statement

Ethical review and approval were waived for this study because its use of already available cumulative published data.

Informed Consent Statement

Patient consent was waived because of publicly available accumulative published data.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors have no conflict of interest to declare.

References

  1. Munoz, J.J.; Ellison, L.M. Upper tract urothelial neoplasms: Incidence and survival during the last 2 decades. J. Urol. 2000, 164, 1523–1525. [Google Scholar] [CrossRef]
  2. Siegel, R.; Ma, J.; Zou, Z.; Jemal, A. Cancer statistics, 2014. CA Cancer J. Clin. 2014, 64, 9–29. [Google Scholar] [CrossRef] [Green Version]
  3. Raman, J.D.; Messer, J.; Sielatycki, J.A.; Hollenbeak, C.S. Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973–2005. BJU Int. 2011, 107, 1059–1064. [Google Scholar] [CrossRef] [PubMed]
  4. Rouprêt, M.; Babjuk, M.; Comperat, E.; Zigeuner, R.; Sylvester, R.; Burger, M.; Cowan, N.; Böhle, A.; Van Rhijn, B.W.; Kaasinen, E. European guidelines on upper tract urothelial carcinomas: 2013 update. Eur. Urol. 2013, 63, 1059–1071. [Google Scholar] [CrossRef] [PubMed]
  5. Rouprêt, M.; Zigeuner, R.; Palou, J.; Boehle, A.; Kaasinen, E.; Sylvester, R.; Babjuk, M.; Oosterlinck, W. European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. Eur. Urol. 2011, 59, 584–594. [Google Scholar] [CrossRef]
  6. Hall, M.C.; Womack, S.; Sagalowsky, A.I.; Carmody, T.; Erickstad, M.D.; Roehrborn, C.G. Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: A 30-year experience in 252 patients. Urology 1998, 52, 594–601. [Google Scholar] [CrossRef]
  7. Ito, K.; Kuroda, K.; Asakuma, J.; Hamada, S.; Tachi, K.; Tasaki, S.; Sato, A.; Horiguchi, A.; Seguchi, K.; Asano, T. Preoperative risk factors for extraurothelial recurrence in patients with ureteral cancer treated with radical nephroureterectomy. J. Urol. 2014, 191, 1685–1692. [Google Scholar] [CrossRef]
  8. Kondo, T.; Nakazawa, H.; Ito, F.; Hashimoto, Y.; Toma, H.; Tanabe, K. Impact of the extent of regional lymphadenectomy on the survival of patients with urothelial carcinoma of the upper urinary tract. J. Urol. 2007, 178, 1212–1217. [Google Scholar] [CrossRef] [PubMed]
  9. Kondo, T.; Tanabe, K. The role of lymph node dissection in the management of urothelial carcinoma of the upper urinary tract. Int. J. Clin. Oncol. 2011, 16, 170–178. [Google Scholar] [CrossRef] [PubMed]
  10. Roscigno, M.; Cozzarini, C.; Bertini, R.; Scattoni, V.; Freschi, M.; Da Pozzo, L.F.; Briganti, A.; Gallina, A.; Capitanio, U.; Colombo, R. Prognostic value of lymph node dissection in patients with muscle-invasive transitional cell carcinoma of the upper urinary tract. Eur. Urol. 2008, 53, 794–802. [Google Scholar] [CrossRef]
  11. Raman, J.D.; Lin, Y.K.; Kaag, M.; Atkinson, T.; Crispen, P.; Wille, M.; Smith, N.; Hockenberry, M.; Guzzo, T.; Peyronnet, B.; et al. High rates of advanced disease, complications, and decline of renal function after radical nephroureterectomy. Urol. Oncol. 2014, 32, 47.e9–47.e14. [Google Scholar] [CrossRef]
  12. Saito, K.; Kawakami, S.; Ohtsuka, Y.; Fujii, Y.; Masuda, H.; Kumagai, J.; Kobayashi, T.; Kageyama, Y.; Kihara, K. The impact of preoperative serum C-reactive protein on the prognosis of patients with upper urinary tract urothelial carcinoma treated surgically. BJU Int. 2007, 100, 269–273. [Google Scholar] [CrossRef]
  13. Kikuchi, E.; Margulis, V.; Karakiewicz, P.I.; Roscigno, M.; Mikami, S.; Lotan, Y.; Remzi, M.; Bolenz, C.; Langner, C.; Weizer, A. Lymphovascular invasion predicts clinical outcomes in patients with node-negative upper tract urothelial carcinoma. J. Clin. Oncol. 2009, 27, 612–618. [Google Scholar] [CrossRef]
  14. Margulis, V.; Shariat, S.F.; Matin, S.F.; Kamat, A.M.; Zigeuner, R.; Kikuchi, E.; Lotan, Y.; Weizer, A.; Raman, J.D.; Wood, C.G. Outcomes of radical nephroureterectomy: A series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer 2009, 115, 1224–1233. [Google Scholar] [CrossRef]
  15. Zigeuner, R.; Shariat, S.F.; Margulis, V.; Karakiewicz, P.I.; Roscigno, M.; Weizer, A.; Kikuchi, E.; Remzi, M.; Raman, J.D.; Bolenz, C. Tumour necrosis is an indicator of aggressive biology in patients with urothelial carcinoma of the upper urinary tract. Eur. Urol. 2010, 57, 575–581. [Google Scholar] [CrossRef] [PubMed]
  16. Rouprêt, M.; Babjuk, M.; Compérat, E.; Zigeuner, R.; Sylvester, R.J.; Burger, M.; Cowan, N.C.; Böhle, A.; Van Rhijn, B.W.; Kaasinen, E.; et al. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Cell Carcinoma: 2015 Update. Eur. Urol. 2015, 68, 868–879. [Google Scholar] [CrossRef]
  17. Favaretto, R.L.; Shariat, S.F.; Chade, D.C.; Godoy, G.; Adamy, A.; Kaag, M.; Bochner, B.H.; Coleman, J.; Dalbagni, G. The effect of tumor location on prognosis in patients treated with radical nephroureterectomy at Memorial Sloan-Kettering Cancer Center. Eur. Urol. 2010, 58, 574–580. [Google Scholar] [CrossRef] [Green Version]
  18. Otto, W.; Shariat, S.F.; Fritsche, H.M.; Gupta, A.; Matsumoto, K.; Kassouf, W.; Martignoni, G.; Walton, T.J.; Tritschler, S.; Baba, S.; et al. Concomitant carcinoma in situ as an independent prognostic parameter for recurrence and survival in upper tract urothelial carcinoma: A multicenter analysis of 772 patients. World J. Urol. 2011, 29, 487–494. [Google Scholar] [CrossRef] [PubMed]
  19. Cho, K.S.; Hong, S.J.; Cho, N.H.; Choi, Y.D. Grade of hydronephrosis and tumor diameter as preoperative prognostic factors in ureteral transitional cell carcinoma. Urology 2007, 70, 662–666. [Google Scholar] [CrossRef]
  20. Rink, M.; Robinson, B.D.; Green, D.A.; Cha, E.K.; Hansen, J.; Comploj, E.; Margulis, V.; Raman, J.D.; Ng, C.K.; Remzi, M. Impact of histological variants on clinical outcomes of patients with upper urinary tract urothelial carcinoma. J. Urol. 2012, 188, 398–404. [Google Scholar] [CrossRef] [PubMed]
  21. Li, W.-M.; Li, C.-C.; Ke, H.-L.; Wu, W.-J.; Huang, C.-N.; Huang, C.-H. The prognostic predictors of primary ureteral transitional cell carcinoma after radical nephroureterectomy. J. Urol. 2009, 182, 451–458. [Google Scholar] [CrossRef]
  22. Kuroda, K.; Asakuma, J.; Horiguchi, A.; Kawaguchi, M.; Shinchi, M.; Masunaga, A.; Tasaki, S.; Sato, A.; Ito, K. Chronic kidney disease and positive surgical margins as prognosticators for upper urinary tract urothelial carcinoma patients undergoing radical nephroureterectomy. Mol. Clin. Oncol. 2019, 10, 547–554. [Google Scholar] [CrossRef] [Green Version]
  23. Stewart, J.H.; Buccianti, G.; Agodoa, L.; Gellert, R.; McCredie, M.R.; Lowenfels, A.B.; Disney, A.P.; Wolfe, R.A.; Boyle, P.; Maisonneuve, P. Cancers of the kidney and urinary tract in patients on dialysis for end-stage renal disease: Analysis of data from the United States, Europe, and Australia and New Zealand. J. Am. Soc. Nephrol. 2003, 14, 197–207. [Google Scholar] [CrossRef] [Green Version]
  24. Tonelli, M.; Wiebe, N.; Culleton, B.; House, A.; Rabbat, C.; Fok, M.; McAlister, F.; Garg, A.X. Chronic kidney disease and mortality risk: A systematic review. J. Am. Soc. Nephrol. 2006, 17, 2034–2047. [Google Scholar] [CrossRef] [Green Version]
  25. Fried, L.F.; Katz, R.; Sarnak, M.J.; Shlipak, M.G.; Chaves, P.H.; Jenny, N.S.; Stehman-Breen, C.; Gillen, D.; Bleyer, A.J.; Hirsch, C. Kidney function as a predictor of noncardiovascular mortality. J. Am. Soc. Nephrol. 2005, 16, 3728–3735. [Google Scholar] [CrossRef] [Green Version]
  26. Liberati, A.; Altman, D.G.; Tetzlaff, J.; Mulrow, C.; Gøtzsche, P.C.; Ioannidis, J.P.; Clarke, M.; Devereaux, P.J.; Kleijnen, J.; Moher, D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. J. Clin. Epidemiol. 2009, 62, e1–e34. [Google Scholar] [CrossRef] [Green Version]
  27. Yu, H.S.; Hwang, J.E.; Chung, H.S.; Cho, Y.H.; Kim, M.S.; Hwang, E.C.; Oh, K.J.; Kim, S.-O.; Jung, S.I.; Kang, T.W. Is preoperative chronic kidney disease status associated with oncologic outcomes in upper urinary tract urothelial carcinoma? A multicenter propensity score-matched analysis. Oncotarget 2017, 8, 66540–66549. [Google Scholar] [CrossRef] [Green Version]
  28. Xylinas, E.; Rink, M.; Margulis, V.; Clozel, T.; Lee, R.K.; Comploj, E.; Novara, G.; Raman, J.D.; Lotan, Y.; Weizer, A.; et al. Impact of renal function on eligibility for chemotherapy and survival in patients who have undergone radical nephro-ureterectomy. BJU Int. 2013, 112, 453–461. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  29. Momota, M.; Hatakeyama, S.; Tokui, N.; Sato, T.; Yamamoto, H.; Tobisawa, Y.; Yoneyama, T.; Yoneyama, T.; Hashimoto, Y.; Koie, T.; et al. The Impact of Preoperative Severe Renal Insufficiency on Poor Postsurgical Oncological Prognosis in Patients with Urothelial Carcinoma. Eur. Urol. Focus 2019, 5, 1066–1073. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  30. Jan, H.C.; Yang, W.H.; Ou, C.H. Combination of the Preoperative Systemic Immune-Inflammation Index and Monocyte-Lymphocyte Ratio as a Novel Prognostic Factor in Patients with Upper-Tract Urothelial Carcinoma. Ann. Surg. Oncol. 2019, 26, 669–684. [Google Scholar] [CrossRef] [PubMed]
  31. Freifeld, Y.; Ghandour, R.; Singla, N.; Woldu, S.; Clinton, T.; Kulangara, R.; Bagrodia, A.; Matin, S.F.; Petros, F.G.; Raman, J.D.; et al. Preoperative predictive model and nomogram for disease recurrence following radical nephroureterectomy for high grade upper tract urothelial carcinoma. Urol. Oncol. 2019, 37, 758–764. [Google Scholar] [CrossRef]
  32. Koguchi, D.; Matsumoto, K.; Ikeda, M.; Taoka, Y.; Hirayama, T.; Murakami, Y.; Utsunomiya, T.; Matsuda, D.; Okuno, N.; Irie, A.; et al. Investigation of estimated glomerular filtration rate and its perioperative change in patients with upper urinary tract urothelial carcinoma: A multi-institutional retrospective study. Asia Pac. J. Clin. Oncol. 2018, 14, e420–e427. [Google Scholar] [CrossRef]
  33. Xing, Y.; Xiong, G.; Fang, D.; Yang, X.; Li, X.; Zhou, L. Prognostic Value of Gene Methylation and Clinical Factors in Non-Muscle-Invasive Upper Tract Urothelial Carcinoma After Radical Nephroureterectomy. Clin. Genitourin. Cancer 2016, 14, e371–e378. [Google Scholar] [CrossRef]
  34. Huang, Y.C.; Chang, Y.H.; Chiu, K.H.; Shindel, A.W.; Lai, C.H. Adjuvant radiotherapy for locally advanced upper tract urothelial carcinoma. Sci. Rep. 2016, 6, 38175. [Google Scholar] [CrossRef] [Green Version]
  35. Yeh, H.C.; Jan, H.C.; Wu, W.J.; Li, C.C.; Li, W.M.; Ke, H.L.; Huang, S.P.; Liu, C.C.; Lee, Y.C.; Yang, S.F.; et al. Concurrent Preoperative Presence of Hydronephrosis and Flank Pain Independently Predicts Worse Outcome of Upper Tract Urothelial Carcinoma. PLoS ONE 2015, 10, e0139624. [Google Scholar] [CrossRef]
  36. Morizane, S.; Yumioka, T.; Yamaguchi, N.; Masago, T.; Honda, M.; Sejima, T.; Takenaka, A. Risk stratification model, including preoperative serum C-reactive protein and estimated glomerular filtration rate levels, in patients with upper urinary tract urothelial carcinoma undergoing radical nephroureterectomy. Int. Urol. Nephrol. 2015, 47, 1335–1341. [Google Scholar] [CrossRef] [PubMed]
  37. Higgins, J.P.; Thompson, S.G.; Deeks, J.J.; Altman, D.G. Measuring inconsistency in meta-analyses. BMJ 2003, 327, 557–560. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  38. Ehdaie, B.; Shariat, S.F.; Savage, C.; Coleman, J.; Dalbagni, G. Postoperative nomogram for disease recurrence and cancer-specific death for upper tract urothelial carcinoma: Comparison to American Joint Committee on Cancer staging classification. Urol. J. 2014, 11, 1435–1441. [Google Scholar] [PubMed]
  39. Lee, K.-H.; Chen, Y.-T.; Chung, H.-J.; Liu, J.-S.; Hsu, C.-C.; Tarng, D.-C. Kidney disease progression in patients of upper tract urothelial carcinoma following unilateral radical nephroureterectomy. Ren. Fail. 2016, 38, 77–83. [Google Scholar] [CrossRef] [Green Version]
  40. Leppert, J.T.; Lamberts, R.W.; Thomas, I.-C.; Chung, B.I.; Sonn, G.A.; Skinner, E.C.; Wagner, T.H.; Chertow, G.M.; Brooks, J.D. Incident CKD after radical or partial nephrectomy. J. Am. Soc. Nephrol. 2018, 29, 207–216. [Google Scholar] [CrossRef]
  41. Clark, M.A.; Shikanov, S.; Raman, J.D.; Smith, B.; Kaag, M.; Russo, P.; Wheat, J.C.; Wolf, J.S.; Matin, S.F.; Huang, W.C. Chronic kidney disease before and after partial nephrectomy. J. Urol. 2011, 185, 43–48. [Google Scholar] [CrossRef]
  42. Yoneyama, T.; Tobisawa, Y.; Yoneyama, T.; Yamamoto, H.; Imai, A.; Mori, K.; Hatakeyama, S.; Hashimoto, Y.; Koie, T.; Ohyama, C. Sequential chemotherapy with gemcitabine plus carboplatin, followed by additional docetaxel for aged patients with advanced upper-tract urothelial cancer. J. Clin. Oncol. 2015, 33, 344. [Google Scholar] [CrossRef]
  43. Birtle, A.; Johnson, M.; Chester, J.; Jones, R.; Dolling, D.; Bryan, R.T.; Harris, C.; Winterbottom, A.; Blacker, A.; Catto, J.W. Adjuvant chemotherapy in upper tract urothelial carcinoma (the POUT trial): A phase 3, open-label, randomised controlled trial. Lancet 2020, 395, 1268–1277. [Google Scholar] [CrossRef]
  44. Von Hoff, D.D.; Schilsky, R.; Reichert, C.M.; Reddick, R.L.; Rozencweig, M.; Young, R.C.; Muggia, F.M. Toxic effects of cis-dichlorodiammineplatinum (II) in man. Cancer Treat. Rep. 1979, 63, 1527–1531. [Google Scholar] [PubMed]
  45. Arany, I.; Safirstein, R.L. Cisplatin nephrotoxicity. Semin. Nephrol. 2003, 23, 460–464. [Google Scholar] [CrossRef]
  46. Pabla, N.; Dong, Z. Cisplatin nephrotoxicity: Mechanisms and renoprotective strategies. Kidney Int. 2008, 73, 994–1007. [Google Scholar] [CrossRef] [Green Version]
Jcm 10 04155 g001 550
Figure 1. A PRISMA flowchart of the literature search strategy used in our meta-analysis and systemic review.
Figure 1. A PRISMA flowchart of the literature search strategy used in our meta-analysis and systemic review.
Jcm 10 04155 g001
Jcm 10 04155 g002 550
Figure 2. Forest plot and funnel plot of progression-free survival after radical nephroureterectomy according to preope-ative renal function. SE: standard error; IV: inverse variance; CI: confidence interval; df: degree of freedom.
Figure 2. Forest plot and funnel plot of progression-free survival after radical nephroureterectomy according to preope-ative renal function. SE: standard error; IV: inverse variance; CI: confidence interval; df: degree of freedom.
Jcm 10 04155 g002
Jcm 10 04155 g003 550
Figure 3. Forest plot and funnel plot of cancer-specific survival after radical nephroureterectomy according to preparative renal function.
Figure 3. Forest plot and funnel plot of cancer-specific survival after radical nephroureterectomy according to preparative renal function.
Jcm 10 04155 g003
Jcm 10 04155 g004 550
Figure 4. Forest plot and funnel plot of overall survival after radical nephroureterectomy according to preoperative renal function.
Figure 4. Forest plot and funnel plot of overall survival after radical nephroureterectomy according to preoperative renal function.
Jcm 10 04155 g004
Table
Table 1. Main characteristics of the eligible studies.
Table 1. Main characteristics of the eligible studies.
Study YearCountryRecruitment PeriodNo. of PatientsProspective Data CollectionInclusion/Exclusion CriteriaConsecutive PatientsDefinition of SurvivalDefinition of eGFR
Xylinas 2013Multination1994–2007666NoYesNAYesYes
Ito 2014Japan1999–201270NoYesNANoYes
Raman 2014Multination2003–2012414NoNoNANoYes
Morizane 2015Japan2000–2012345NoYesNAYesNo
Yeh 2015Taiwan1991–2013472NoYesNANoYes
Huang 2016Taiwan2001–2016198NoYesNANoYes
Xing 2016China2000–2013192NoYesNANoYes
Yu 2017Korea2004–2014566NoYesNANoYes
Koguchi 2018Japan1990–2015433NoYesNANoYes
Freifeld 2019USA1993–2016245NoYesNANoNo
Jan 2019Taiwan2007–2017424NoYesNANoYes
Kuroda 2019Japan1999–2017187NoNoNANoYes
Momota2019Japan1995–2017456NoYesNANoYes
eGFR: estimated glomerular filtration rate; NA: not available.
Table
Table 2. Patient characteristics of the eligible studies.
Table 2. Patient characteristics of the eligible studies.
Study Median Age,
Range (Years)		Gender (Male/Female)Median BMI, Range (kg/m2)ECOG
Performance Status
(0/1/2/3)		SmokingSurgical Approach
(Open/Laparoscopic)		Median Follow-Up,
Range (Months)
Xylinas 69.6, 54–76441/22528.2, 24–32 (IQR)445/221 (1–3)NA519/14745.5, 24–67 (IQR)
Ito NA47/23NANANA49/2129.2, 1–157
Raman 70, 27–96257/157NA82/165/159/8NANA16, 2–120
Morizane 74, 38–95234/11122.1, 13–34.2241/103 (1–3)175244/10139.9, 6.1–160
Yeh 67, 24–95204/268NANA99269/20333, 1–233
Huang 68.6, 23.6–91.6103/95NANA26NA29.1, 6.4–164.9
Xing NA78/114NANANA84/14565, 3–144
Yu 72, 65–76 (IQR)165/401NA399/148/20/1NA142/42431.1, 16.2–55.7
Koguchi 69, 62–75 (IQR)313/120NANA138243/19035.4, 13.8–74.5 (IQR)
Freifeld 70 (mean)152/9329 (mean)126/98 (1–3)NANA27
Jan 70, 29–96189/235NANA49NA35, 14–60 (IQR)
Kuroda 71, 38–90138/49NANANA104/8349.2, 3.4–209.2
MomotaNA309/147NA446 (0–1)/10 (2–3)NA377/7940
BMI: body mass index; ECOG: Eastern Cooperative Oncology Group; IQR: interquartile range; NA: not available.
Table
Table 3. Tumor characteristics of the eligible studies.
Table 3. Tumor characteristics of the eligible studies.
Study History of Bladder CancerHydronephrosisTumor SizeTumor Location
(Pelvis/Ureter)		Tumor Multifocality Adjuvant Chemotherapy
Xylinas 244NANA420/24616462
Ito 1726NA0/70723
Raman NANANANANA55
Morizane 36201NA140/20551NA
Yeh NANANA189/1939087
Huang 49NANANANA21
Xing NA119NA102/9052NA
Yu 111249NA258/30849205
KoguchiNANANA239/194NA99
Freifeld 80713.4 (mean)116/8535NA
Jan 127344NA191/13811640
Kuroda 47112NANANANA
Momota NA288NA175/254NA64
NA: not available.
Table
Table 4. Pathologic characteristics of the eligible studies.
Table 4. Pathologic characteristics of the eligible studies.
Study Tumor Grade
(Low/High)		Pathologic T Stage
(pT0/Is/a/1/2/3/4)		Pathologic
N Stage
(pNx/−/+)		Variant
Form		LVIConcomitant
CIS		Positive
Surgical Margin
Xylinas 121/533326 (≤T1)/118/182/40291/291/84NA171229NA
Ito NANANANANANANA
Raman 116/2983/16/106/60/60/143/26165/203/46NANANA25
Morizane 222/109188 (≤T2)/152 (≥T3)205/119/21291024322
Yeh 112/3600/60(Tis/a)/130/112/142/28261/170/418NANANA
Huang 11/147198 (T3)198 (N0)NA31205
Xing 170/2230 (Ta)/162 (T1)192 (N0)NANANANA
Yu 182/3880/84 (Tis/a)/128/134/200/20NANA11954NA
Koguchi 300/1270/18/66/91/81/153/24181/221/31NA151NA30
Freifeld NANANANANANANA
Jan 22/4020/0/161 (Ta/1)/83/180 (T3/4)399 (Nx/−)/25NA115NANA
Kuroda 55/13296 (≤T2)/91 (≥T3)0/172/15NA652221
Momota 24/432260 (≤T2)/196 (≥T3)431 (Nx/−)/25NA160NA15
LVI: lymphovascular invasion; CIS: carcinoma in situ; NA: not available.
Table
Table 5. Estimation of hazard ratios.
Table 5. Estimation of hazard ratios.
StudySurvival AnalysisThreshold of eGFR (mL/min/1.73 m2)Co-FactorsAnalysis Results
Xylinas OS60Standard clinico-pathological featuresNot significant
Ito PFS60cT stage (T3), length of cancer (3 cm), maximal diameter of cancer (1.6 cm), NLR (3)Significant
Raman CSS60Gender, race, age (70 years), ECOG performance status (0,1/2,3), pT stage (T3/T4), LN status, surgical margin status, adjuvant chemotherapyNot significant
Morizane CSS50ECOG performance status (0/≥1), number of tumor (1/>1), CRP (0.5)Significant
Yeh CSS/OS60Gender, age (67 years), smoking, surgery method (laparoscopic/open), tumor location, pT stage, pN stage, tumor grade, adjuvant chemotherapy, hematuria, hydronephrosis and flank painSignificant/Significant
Huang PFS/CSS/OS60Gender, age (68.6 years), current smoking, ASA score, recurrent bladder tumor, recurrent contralateral UTUC, tumor grade, LVI, CIS, surgical margin status, adjuvant radiotherapy, adjuvant chemotherapySignificant/Significant/Significant
Xing CSS30ABCC6 methylation, GDF15 methylation, tumor multifocality, surgery method (laparoscopic/open)Significant
YuPFS60BMI, pT stage (≤T2/≥T3), tumor grade, LVISignificant
CSS60DM, pT stage (≤T2/≥T3), tumor grade, LVI, adjuvant chemotherapySignificant
OS60Age, BMI, ECOG performance status(0,1/2,3), tumor size, tumor multifocality, pT stage (≤T2/≥T3), tumor grade, LVI, adjuvant chemotherapySignificant
KoguchiPFS/OS60Change rate of eGFR, age, gender, tumor location, tumor grade, pT stage, pN stage, LVI, surgical margin statusNot significant/Not significant
Freifeld PFS50Age (66 years), ECOG performance status (0/≥1), hemoglobin, hydronephrosis, pT stage (≤T2/≥T3), tumor architectureNot significant
Jan PFS/CSS/OS60Gender, blood type, age (69 years), smoking, hemodialysis, DM or hypertension, previous or concomitant bladder cancer, hydronephrosis, hematuria, pT stage, pN stage, tumor grade, LVI, tumor location, tumor multifocality, tumor size (3 cm), tumor architecture, tumor necrosis, adjuvant chemotherapy, NLR (4), PLR (150), MLR (0.4), SII (580)Not significant/Not significant/Not significant
Kuroda PFS60Tumor histology, pT stage (≤T2/≥T3), tumor grade, pN stage, surgical margin status, LVI, CAR (0.079, NLR (2.035), PLR (165), GPS (1), fibrinogen (337)Significant
CSS60Urine cytology, tumor histology, pT stage (≤T2/≥T3), tumor grade, pN stage, surgical margin status, LVI, CAR (0.079, NLR (2.035), PLR (165), GPS (1), fibrinogen (337)Significant
Momota PFS/CSS/OS60age, gender, ECOG performance status, hypertension, CVD, DM, neoadjuvant chemotherapy, hydronephrosis,
tumour location, tumor grade, pT stage (≤T2/≥T3), pN stage, LVI		Significant/Not significant/Not significant
eGFR: estimated glomerular filtration rate; OS: overall survival; PFS: progression-free survival; NLR: neutrophil-to-lymphocyte ratio; CSS: cancer-specific survival; ECOG: Eastern Cooperative Oncology Group; LN: lymph node; CRP: C-reactive protein; ASA: American Society of Anesthesiologists; UTUC: upper tract urothelial carcinoma; LVI: lymphovascular invasion; CIS: carcinoma in situ; BMI: body mass index; DM: diabetes mellitus; PLR: platelet-to-lymphocyte ratio; MLR: monocyte-to-lymphocyte ratio; SII: systemic immune-inflammation index; CAR: C-reactive protein-to-albumin ratio; GPS: Glasgow prognostic score; CVD: cardiovascular disease.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Kim, M.H.; Yuk, H.D.; Jeong, C.W.; Kwak, C.; Kim, H.H.; Ku, J.H. Estimated Glomerular Filtration Rate as a Prognostic Factor in Urothelial Carcinoma of the Upper Urinary Tract: A Systematic Review and Meta-Analysis. J. Clin. Med. 2021, 10, 4155. https://doi.org/10.3390/jcm10184155

AMA Style

Kim MH, Yuk HD, Jeong CW, Kwak C, Kim HH, Ku JH. Estimated Glomerular Filtration Rate as a Prognostic Factor in Urothelial Carcinoma of the Upper Urinary Tract: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2021; 10(18):4155. https://doi.org/10.3390/jcm10184155

Chicago/Turabian Style

Kim, Min Hyuk, Hyeong Dong Yuk, Chang Wook Jeong, Cheol Kwak, Hyeon Hoe Kim, and Ja Hyeon Ku. 2021. "Estimated Glomerular Filtration Rate as a Prognostic Factor in Urothelial Carcinoma of the Upper Urinary Tract: A Systematic Review and Meta-Analysis" Journal of Clinical Medicine 10, no. 18: 4155. https://doi.org/10.3390/jcm10184155

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop