Review article
Perioperative blood transfusion affects oncologic outcomes after nephrectomy for renal cell carcinoma: A systematic review and meta-analysis

https://doi.org/10.1016/j.urolonc.2019.01.018Get rights and content

Highlights

  • Blood transfusion affects oncologic outcomes in renal cell carcinoma

  • Blood transfusion affects overall mortality in nonmetastatic renal cell carcinoma

  • The mechanism of the association needs to be uncovered.

Abstract

Aim: To investigate the association of perioperative blood transfusion (PBT) with oncologic outcomes in patients with renal cell carcinoma (RCC), we conducted a systematic review and meta-analysis of the literature to clarify the long-term oncologic effect of PBT in patients undergoing nephrectomy for RCC. Materials and methods: We searched the MEDLINE, Web of Science, Cochrane Library and Scopus on 15th April 2018 to identify studies that compared patients who received PBT undergoing radical or partial nephrectomy for RCC to patients who did not with the aim of evaluating its impact on overall mortality (OM), cancer-specific mortality (CSM) and disease recurrence using multivariable cox regression analysis. Results: A total of 19,681 patients in 7 studies matched the selection criteria for the systematic review and meta-analysis. All 7 studies were retrospective design and published between 1994 and 2018. Our study included low quality of eligible studies due to their retrospective design and showed a significant heterogeneity. PBT was associated with OM (pooled hazard ratio [HR], 1.49, 1.24–1.78), CSM (pooled HR, 1.46, 1.20–1.77), and disease recurrence (pooled HR, 1.80, 1.03–3.12). In a subgroup analysis of 3,664 patients with nonmetastatic RCC, PBT was remained associated with OM (pooled HR, 1.91; 1.06–3.41), but not anymore with CSM (pooled HR, 1.92, 0.94–3.91) or disease recurrence (pooled HR, 2.18, 0.86–5.55). Conclusions: PBT in patients undergoing nephrectomy for RCC is associated with worse overall survival. While PBT may be reflective of the underlying aggressiveness of the disease, it could be that its detrimental effect on outcomes is caused by its negative effect on the host's resilience.

Introduction

Renal cell carcinoma (RCC) is associated with approximately 84,400 new cases and leads to 34,700 deaths per year in the European Union countries alone [1]. Standard treatment for most RCC is surgical removal of the primary tumor [2]. Despite adequate surgery, 10% to 20% of patients with seemingly localized RCC treated with radical or partial nephrectomy experience local and/or distant recurrence [3,4]. RCC is a highly vascular disease with significant angiogenetic activity leading potentially higher blood loss compared to other diseases [5].

PBT has been associated with worse oncologic outcomes in several malignancies [6], [7], [8]. It has been hypothesized that PBT has an immunosuppressive effect, but the definitive mechanism underlying this association has not been uncovered yet [9]. In RCC, Soubra et al. reported, in a population-based study, that PBT was associated with overall mortality (OM) and cancer specific mortality (CSM) in 14,379 patients treated with nephrectomy [10]. Several other studies have provided further evidence on the prognostic value of PBT on RCC outcomes after nephrectomy [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]. However, all studies suffer from common limitations such as single center design, small sample size, short follow-up and lack of data regarding confounding factors. No study to date had a prospective controlled design to allow for robust evidence to change clinical practice. We hypothesized that PBT might impact prognosis in patients with RCC after surgical treatment. To elucidate this, we conducted a systematic review and meta-analysis of the literature to survey the association of PBT with oncologic outcomes such as OM, CSM and disease recurrence in patients who had undergone surgical treatment for RCC.

Section snippets

Materials and methods

A completed PRISMA-P 2015 checklist is shown in the Supplementary table 1 to describe the methodology of our study clearly. The protocol has also been registered in the International Prospective Register of Systematic Reviews database (PROSPERO: CRD42018096910).

Study selection and characteristics

Our initial search identified 679 records. After removal of duplicates, 450 remained (Fig. 1). After screening the titles and abstracts, 388 articles were excluded. Then, we assessed full texts for selection leaving 7 studies for the qualitative and quantitative evidence synthesis including 19,681 patients.

The baseline characteristics of the 7 studies are outlined in Table 1. All included studies had a retrospective design and were published between 1994 and 2018 with 3 being from Europe, 3

Discussion

We investigate the association of PBT with oncologic outcomes in RCC patients treated with radical or partial nephrectomy. To the best of our knowledge, our study is the first systematic review and meta-analysis evaluating the association of PBT with oncologic outcomes. We relied on data from 7 published studies with a combined patient population of more than 19,000 patients. PBT was associated with significantly increased risks of OM, CSM and disease recurrence when all RCC patients treated

Conclusions

This systematic review and meta-analysis shows that PBT is significantly associated with OM, CSM and disease recurrence in patients treated with partial or radical nephrectomy for RCC. In nonmetastatic RCC patients, PBT is significantly associated with OM, but not anymore with cancer specific survival outcomes. However, current data is low quality and there is significant heterogeneity among included studies. Therefore, our findings should be validated in prospective cohorts.

Conflict of interest

No conflict of interest disclosures from any authors.

Author Contributions

Project development: T Iwata, S Kimura, PI Karakiewicz, F Preisser, Y Nasu, SF Shariat

Data collection: T Iwata, S Kimura, B Foerster

Data analysis: T Iwata, S Kimura, B Foerster, M Abufaraj

Manuscript writing/editing: T Iwata, S Kimura, B Foerster, M Abufaraj, PI Karakiewicz, F Preisser, Y Nasu, SF Shariat.

References (39)

  • M Rieken et al.

    Predictors of cancer-specific survival after disease recurrence in patients with renal cell carcinoma: the effect of time to recurrence

    Clin Genitourin Cancer

    (2018)
  • SE Eggener et al.

    Renal cell carcinoma recurrence after nephrectomy for localized disease: predicting survival from time of recurrence

    J Clin Oncol

    (2006)
  • L Richstone et al.

    First Prize (tie): hemorrhage following percutaneous renal surgery: characterization of angiographic findings

    J Endourol

    (2008)
  • CC Wang et al.

    Perioperative factors affecting long-term outcomes of 473 consecutive patients undergoing hepatectomy for hepatocellular carcinoma

    Ann Surg Oncol

    (2009)
  • A Amato et al.

    Perioperative blood transfusions for the recurrence of colorectal cancer

    Cochrane Database Syst Rev

    (2006)
  • Y Abu-Ghanem et al.

    Perioperative blood transfusion adversely affects prognosis after nephrectomy for renal cell carcinoma

    Urol Oncol

    (2018)
  • RP Kopp et al.

    Survival outcomes after radical and partial nephrectomy for clinical T2 renal tumours categorised by RENAL nephrometry score

    BJU Int

    (2014)
  • BJ Linder et al.

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

    BJU Int

    (2014)
  • YH Park et al.

    Association between perioperative blood transfusion and oncologic outcomes after curative surgery for renal cell carcinoma

    J Cancer

    (2016)
  • Cited by (11)

    View all citing articles on Scopus

    Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

    1

    Takehiro Iwata and Shoji Kimura contributed equally to this project.

    View full text