Acute kidney injury (AKI) and end stage kidney disease (ESKD) in CKD patients undergoing partial or radical nephrectomy for renal cancer: are we ready to unravel the uncertainty and create new hope?

Background and objective: Patients with moderate to severe preoperative chronic kidney disease (CKD) are often considered at high risk for postoperative acute kidney injury (AKI) and progression to end-stage kidney disease (ESKD), especially when radical nephrectomy (RN) is required. This study evaluated the impact of preoperative CKD on AKI and ESKD risk in patients undergoing RN or partial nephrectomy (PN) for localized renal masses. Methods: We retrospectively analyzed 1,194 patients with cT1–2 cN0 cM0 renal masses treated at a tertiary center. CKD was staged using KDIGO 2024 guidelines; eGFR was calculated with the 2021 CKD-EPI formula. Postoperative AKI and ESKD were defined per KDIGO 2024. Logistic regression adjusted for age, comorbidity (Charlson Comorbidity Index), tumor size, and surgery type was performed. Results: Overall, 8.9% had CKD stage 3b–4. AKI occurred in 19.9%, and ESKD in 2.3%. PN reduced AKI risk (aOR 0.19, p < 0.001) but did not significantly reduce ESKD risk (p = 0.550). Advanced CKD was associated with higher ESKD rates (9.4% vs. 1.7%, p < 0.001) and more complications. However, many stage 3b–4 patients did not develop severe AKI or ESKD. Age and comorbidity were strong predictors of adverse outcomes. Older age and higher comorbidity scores further heightened the likelihood of adverse renal outcomes. Conclusions: Preoperative CKD increases the risk of AKI and ESKD, especially with RN. PN lowers AKI risk but does not eliminate long-term decline. Despite expectations, many high-risk patients maintain better-than-expected renal outcomes. These findings support personalized surgical decisions and reinforce the need for nephrology involvement in perioperative care. Patient summary: In this study, we examined kidney outcomes after surgery for kidney cancer in patients with chronic kidney disease. We found that partial nephrectomy reduced the risk of short-term kidney injury. Importantly, many high-risk patients did not require dialysis after surgery.