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Variation in Use of Nephron-Sparing Surgery among Children with Renal Tumors
David I. Chu, MD, Jessica C. Lloyd, MD, Zarine R. Balsara, MD, PhD, John S. Wiener, MD, Sherry S. Ross, MD, Jonathan C. Routh, MD, MPH.
Duke University Medical Center, Durham, NC, USA.

BACKGROUND:
As awareness of the long-term effects of renal insufficiency is growing, nephron-sparing surgery (NSS) is increasingly discussed for the treatment of pediatric renal tumors. Children are at potentially higher risk of chronic kidney disease than are adults, due mainly to their younger age and thus their increased number of years at risk. We therefore sought to examine variation in practice patterns of NSS among children with renal tumors.
METHODS:
A retrospective cohort analysis of claims data for pediatric inpatient admissions captured by the Kids Inpatient Database (KID) (1997-2009) was performed. KID is a triennial, stratified sample of pediatric discharges from community hospitals in participating states, including 10% of uncomplicated births and 80% of all other pediatric discharges. In 2009, for example, 4,121 hospitals from 44 states contributed information. ICD-9 codes from each inpatient hospitalization were utilized to identify children with renal tumors who underwent surgical intervention defined as radical nephrectomy (RN), NSS, or biopsy. Bivariate tests of association and multivariable logistic regression were used to assess the relationship between use of NSS and clinical factors such as renal failure, patient age and socioeconomic status, hospital location and teaching status, and other predictors of interest. Tumor bilaterality could not be accurately assessed due to lack of adequate coding granularity.
RESULTS:
A total of 10,108 pediatric inpatient admissions for renal tumors were identified. Of these, 1,649 were surgical admissions accounting for 1,676 total extirpative procedures, after exclusion of biopsy-only procedures. RN constituted 1,496 (89.3%) of these procedures, and 180 (10.7%) were NSS. On bivariate analysis, hospital region and diagnosis of renal failure/insufficiency were significant predictors of NSS. Regionally, 14.9% of hospitals in the Northeast used NSS, followed by 11.6% in the West, 9.3% in the South, and 8.8% in the Midwest (p=0.03). For renal failure, 22.5% of patients with versus 10.6% of those without renal failure underwent NSS (p=0.02). On multivariable analysis, NSS was again associated only with a concomitant diagnosis of renal failure/insufficiency (Odds Ratio (OR) 2.47, 95% Confidence Interval (CI) 1.08-5.63, p=0.03) and hospital location in the Northeast (OR 1.89, 95% CI 1.13-3.16, p=0.02). Race/ethnicity, age, payer type, children’s hospital designation, year of procedure, and other factors were not significantly associated with NSS on multivariable analysis.
CONCLUSIONS:
In a large, nationwide pediatric cohort, RN remained the most common primary surgical intervention for pediatric renal tumors. However, over the study period NSS was consistently performed in 11% of pediatric renal tumor cases; this is more common than would be expected if NSS were used solely in bilateral or syndromic renal tumors. Importantly, we noted significant regional variation in the use of NSS and association with a concomitant diagnosis of renal failure/insufficiency, but not with any other clinical or socioeconomic factors.


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