PURPOSE:Accurate assessment of renal function is critical in the management of renal cell carcinoma (RCC), influencing surgical planning, systemic therapy eligibility, and clinical trial inclusion. Estimated glomerular filtration rate (eGFR) equations are commonly used in clinical practice but may not reflect true kidney function when compared with more accurate methods of determining renal function such as measured GFR using 24-hour urine creatinine clearance. METHODS:In this prospective study, 72 patients with nonmetastatic RCC undergoing preoperative evaluation completed serum creatinine, cystatin C, and 24-hour urine collections. eGFR values were calculated using multiple established equations, both race-inclusive and race-neutral. The agreement between eGFR and measured GFR was assessed using Passing-Bablok regression. Linear regression estimated the discrepancy between eGFR and measured GFR at clinically relevant cutoffs of 45 and 60 mL/min/1.73 m2. RESULTS:Across all equations, eGFR consistently overestimated renal function compared with measured GFR. At a measured GFR of 45, corresponding eGFR values ranged from 53 to 59 mL/min/1.73 m2; at a measured GFR of 60, eGFR values ranged from 63 to 68 mL/min/1.73 m2. The greatest overestimation was observed with race-neutral Chronic Kidney Disease Epidemiology Collaboration 2021 equations. CONCLUSION:eGFR equations significantly overestimate renal function in patients with renal masses when compared with 24-hour CrCl-derived measured GFR, particularly near clinically meaningful thresholds. This misclassification may result in inappropriate exposure to potentially harmful treatments, including nephrotoxic chemotherapy and radical nephrectomy. Confirmatory measured GFR testing should be considered in patients with renal function within a ±10 mL/min/1.73 m2 range of clinically significant cutoff values to ensure accurate, safe, and appropriate therapeutic decision making. Clinical guidance should specify whether physicians should use eGFR or measured GFR when determining eligibility.

Introduction: Frailty is associated with worsened perioperative outcomes, and well studied tools like the Fried Frailty Index are impractical in busy clinical settings. This study evaluated the utility of clinic administered Timed Up & Go (TUG) test and the modified frailty index-5 (MFI-5) in identifying frail patients prior to urologic surgery. Methods: We retrospectively analyzed data from 106 patients in with concurrent Fried, TUG, and MFI-5 scores. Spearman's rank correlation assessed relationships among measures, and diagnostic accuracy was used to identify optimal cutoffs. Results: Of the cohort, 38.7 % were frail as measured by the gold standard Fried Frailty Index, TUG and MFI-5 scores were significantly higher in frail patients. TUG showed moderate correlation with Fried frailty achieving an area under the curve (AUC) of 0.794, while MFI-5 was mildly correlated with an AUC of 0.612. A TUG >= 11 s and MFI-5 >= 0.3 offered the highest classification accuracy. Conclusions: TUG better correlated with Fried frailty status than MFI-5 with a TUG >= 11 s best predicting frailty in our cohort. Synopsis: Fried frailty predicts poor surgical outcomes but is impractical to assess. Among urologic cancer patients, Timed Up and Go (TUG) moderately correlated with Fried frailty and may offer a practical, objective, and reliable alternative for measuring frailty.

Sarcopenia, defined as the loss of skeletal muscle mass and function, is associated with worse postoperative outcomes and reduced survival in patients undergoing surgery for solid tumours, including renal cell carcinoma (RCC). Although radiographic assessment using the skeletal muscle index (SMI) at the L3 vertebral level has emerged as a method for quantifying sarcopenia, a consensus on optimal sarcopenia thresholds, especially in non-metastatic RCC, remains lacking. This study aims to evaluate which of the existing published SMI thresholds can be utilized to predict overall survival (OS) in a racially diverse non-metastatic (nmRCC) cohort. We retrospectively reviewed 343 patients with any T-stage nmRCC who underwent nephrectomy between 2007 and 2022 at our institution. SMI (cm 2 /m 2 ) values were calculated using cross-sectional imaging at the L3 level. Six published sarcopenia thresholds were applied. Associations between threshold-defined sarcopenia and OS were evaluated using Kaplan–Meier curves and Cox proportional hazards models adjusted for confounding variables. Three hundred forty-three patients met inclusion criteria, 62.7% were White, and 33.2% were Black. Median follow-up time was 41.5 months (IQR 17.8–61.7 months), during which there were 62 (18.1%) mortality events. Median SMI measurements for males and females in our cohort were 51.1 and 42.4 cm/m 2 , respectively. Patients defined as radiographically sarcopenic using thresholds by Derstine et al. (HR 2.11 [95% CI 1.14–3.91], p  = 0.018) and Tonnesen et al. (HR 2.11 [95% CI 1.15–4.53], p  = 0.028) had independently associated worse OS. Notably, these thresholds were constructed from healthy adult populations. SMI thresholds derived from healthy cohorts, as proposed by Derstine et al., are associated with OS in patients with nmRCC and may serve as clinically practical tools for identifying high-risk patients. Incorporating radiographic sarcopenia assessment into preoperative workflows may facilitate targeted prehabilitation interventions aimed at improving survival outcomes in this population.

Background: Frailty is frequently observed among patients undergoing major oncologic surgery, yet physical therapy (PT) utilization in urologic oncology remains underreported. This study aimed to identify predictors of inpatient PT utilization and assess its impact on functional outcomes using the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" tool. Methods: The Emory Frailty Database was retrospectively reviewed, including patients >= 18 years who underwent urologic oncologic surgery from 2013 to 2019. Demographics, comorbidities, frailty status, surgical approach, hospital length of stay (LOS), and discharge destination were collected. Utilization of PT, number of sessions, and "6-Clicks" scores were recorded. Multivariable regression assessed predictors of PT utilization. Pre- and post-PT "6-Clicks" scores were compared using Wilcoxon signed-rank tests. Results: Of 194 patients, 54 (27.8%) received inpatient PT. Patients receiving PT were more likely to be frail/pre-frail (P = .005), have higher comorbidity burdens [Charlson comorbidity index (CCI) >= 4, P < .001], undergo open procedures (P < .001), and experience prolonged LOS (P < .001). On multivariable analysis, CCI >= 4 (OR 1.69, P = .04) and prolonged LOS (OR 1.69, P < .001) independently predicted PT utilization. Among 21 patients with pre- and post-intervention scores, median "6-Clicks" scores improved significantly (16-20, P = .003). 20 (44%) of frail/prefrail patients utilized PT postoperatively. Conclusion: Comorbidity burden and prolonged hospitalization, rather than frailty alone, independently predicted PT referral following urologic cancer surgery. Short-term functional outcomes significantly improved following PT, suggesting that standardized referrals based on objective criteria may optimize recovery and mitigate biases influencing referrals. Given fewer than 50% of frail patients utilized PT, implementation of frailty screening tools may improve postoperative outcomes.

380 Background: Baseline sarcopenia and postoperative changes in muscle mass are independently associated with overall survival in patients with metastatic renal cell carcinoma (mRCC) undergoing cytoreductive nephrectomy (CN). Here we examine the relationship between preoperative (baseline) and postoperative changes in muscle quantity with survival outcomes following CN as determined by linear segmentation, a fast and clinic-friendly tool. Methods: Our nephrectomy database was reviewed for patients with clear cell, papillary, or chromophobe mRCC who underwent CN. Linear segmentation of bilateral psoas/paraspinal muscles was completed for baseline imaging within 60 days of surgery and imaging up to 1 year postoperatively. ANOVA for numerical and chi-square for categorical variables were used to test for differences according to change in linear muscle index (LMI, cm2/m2). Multivariable models estimated COX hazard ratios for cancer-specific survival (CSS) and overall survival (OS). Kaplan Meier curves estimated CSS and OS. Results: From 2004-2020, 190 patients were identified 48 stable LMI (25.3%; <5% change [0Δ]), 54 increase LMI (28.4%; +5% change [+Δ]), and 88 decrease LMI (46.3%; -5% change [-Δ]). Median time from baseline imaging to surgery was 18 days, while time from surgery to postoperative imaging was 119 days. Patients with +Δ had lower baseline LMI than -Δ or 0Δ (28.5 vs. 32.4 vs.32.5 cm2/m2; p=0.003). 0Δ LMI had lower rates of pN1 disease than other groups (27.1% [0Δ] vs. 42.6% [+Δ] vs. 45.5% [-Δ]; p=0.019). No other differences in pathology were noted. Median CSS and OS were highest among patients with 0Δ LMI (CSS: not reached [0Δ] vs. 61.9 [+Δ] vs. 37.4 [-Δ] months; p=0.0018 || OS: 67.2 [0Δ] vs. 48.5 [+Δ] vs. 26.4 [-Δ] months; p=0.0007). Median follow-up was 56 months for survivors. The table lists factors associated with increased risk of cancer-specific mortality. Conclusions: Change in muscle mass after CN, as measured by the linear muscle segmentation technique, is independently associated with OS and CSS in patients following CN. Of note, lack of change demonstrated greatest survival, potentially secondary to high baseline muscle mass. [Table: see text]

IntroductionBaseline sarcopenia and postoperative changes in muscle mass are independently associated with overall survival (OS) in patients with metastatic renal cell carcinoma (mRCC) undergoing cytoreductive nephrectomy (CN). Here we examine the relationships between preoperative (baseline), postoperative changes in muscle quantity, and survival outcomes following CN as determined by linear segmentation, a clinic-friendly tool that rapidly estimates muscle mass.Materials and MethodsOur nephrectomy database was reviewed for patients with metastatic disease who underwent CN for RCC. Linear segmentation of the bilateral psoas/paraspinal muscles was completed for baseline imaging within 60 days of surgery and imaging 30 to 365 days postoperatively. Kruskal-Wallis for numerical and Fisher's exact test for categorical variables were used to test for differences between groups according to percent change in linear muscle index (LMI, cm2/m2). Multivariable Cox proportional hazards models evaluated associations between LMI percent change and cancer-specific (CSM) and all-cause mortality (ACM). Kaplan Meier curves estimated cancer-specific (CSS) and overall survival (OS).ResultsFrom 2004-2020, 205 patients were included of whom 52 demonstrated stable LMI (25.4%; LMI change < 5% [0Δ]), 60 increase (29.3%; LMI +5% [+Δ]), and 92 decrease (44.9%; LMI -5% [-Δ]). Median time from baseline imaging to surgery was 18 days, and time from surgery to postoperative imaging was 133 days. Median CSS and OS were highest among patients with 0Δ LMI (CSS: 133.6 [0Δ] vs. 61.9 [+Δ] vs. 37.4 [-Δ] months; P = .0018 || OS: 67.2 [0Δ] vs. 54.8 [+Δ] vs. 29.5 [-Δ] months; P = .0007). Stable LMI was a protective factor for CSM (HR 0.48; P = .024) and ACM (HR 0.59; P = .040) on multivariable analysis.DiscussionChange in muscle mass after CN, as measured by the linear muscle segmentation technique, is independently associated with OS and CSS in patients following CN. Of note, lack of change was associated with longer survival.

Purpose: Drain evaluation and management is an essential skill for practicing surgeons. There are a multitude of laboratory analyses that may assist in the elucidation of a drain fluid source. Our goal is to review the current biochemical analyses of drain fluid available in an effort to guide perioperative management. Materials and methods: A PubMed search of all available English language literature for drain fluid analysis following urologic and general surgeries was conducted. Further sources were identified in the reference lists of identified articles. All relevant articles published were reviewed and used to delineate the appropriate drain fluid tests that could be ordered. The interpretation of these test results was also discussed. The data was then presented in a series of patient scenarios that exemplify postoperative complications seen. Results: Biochemical analysis of drain fluid can be used to assist in the diagnosis of the postoperative urologic tract, intestinal, hepatopancreaticobiliary, and infectious complications. Drain fluid studies including creatinine, urea, triglyceride, cell count, protein, pH, specific gravity, gram stain, culture, lactate dehydrogenase, amylase, lipase, albumin, bilirubin, and alkaline phosphatase have been reviewed accordingly. Conclusions: Commonly available laboratory analyses may assist the surgeon in perioperative drain management. Our review summarizes these studies through case examples. Understanding the applicability of these studies is essential to improve surgical practice. Synopsis: A review of drain fluid evaluation and management in genitourinary procedures as depicted in a caseby-case fashion. This article demonstrates the indications and utilities of drain fluid studies in postoperative patients to best assist and inform surgical practice.

697 Background: Creatinine and cystatin C are routinely used to assess renal function. Given creatinine originates from skeletal muscle and cystatin C is produced by nucleated cells, a creatinine to cystatin C ratio (Cr/Cys-C) may positively correlate with muscle mass. Low Cr/Cys-C has also been associated with decreased overall survival (OS) in cancer, including in a combined cohort of genitourinary malignancies. Furthermore, elevated cystatin c has been associated with shorter OS and recurrence free survival (RFS) in renal cell carcinoma (RCC). Cr/Cys-C may be a simple and affordable tool to assist with patient-specific risk stratification. We assess the ability of Cr/Cys-C to predict OS and RFS in patients with RCC. Methods: Retrospective review of a prospectively maintained database identified patients that underwent partial or radical nephrectomy for RCC from 2018-2021. Included patients had preoperative creatinine and cystatin C and 1+ year of follow up. Cr/Cys-C associations with patient/tumor characteristics were determined by generalized chi-square or Fisher’s exact tests for categorical variables and Wilcoxon rank-sum test for continuous variables. Cr/Cys-C ability to predict OS and RFS was analyzed with Kaplan-Meier method and Cox hazards models. Statistical tests were two-sided with type I error set at 0.05. Results: 219 patients were identified. Median age was 64, with most being male (67%). 62% and 29% of patients were white and black, respectively. Median eGFR was 72mL/min/1.73m2. Median (IQR) Cr/Cys-C was 1 (0.8-1.2). 55% were stage T3-T4, with 12% N1 and 16% M1 at time of surgery. 72% had clear cell histology. Low Cr/Cys-C was significantly associated with older age, males, Eastern Cooperative Oncology Group score ≥ 1, radical nephrectomy, T3-T4 stage, and metastasis. Kaplan-Meier curves showed low Cr/Cys-C association with decreased OS (p=0.0003) and RFS (p=0.0094). Cox regression analysis revealed lower Cr/Cys-C as independent predictor of decreased OS (binary HR=3.66, 95% CI 1.2-11.3, p=0.02; continuous HR=0.05, 95% 0.0-0.8, p=0.03) and RFS (binary HR=4.8, 95% CI 1.6-14.6, p=0.006; continuous HR=0.02, 95% 0.0-0.3, p=0.006;Table). Conclusions: Lower Cr/Cys-C may be associated with decreased OS and RFS in patients with RCC. [Table: see text]

Low muscle mass, defined as sarcopenia, is a risk factor for worse outcomes in malignancy, including renal cell carcinoma. This study evaluates the association of low muscle mass with mortality and complications in patients with renal cell carcinoma with venous tumor thrombus. Preoperative sarcopenia was associated with worse overall and cancer specific survival. Background: Renal cell carcinoma (RCC) with tumor thrombosis often requires nephrectomy and tumor thrombectomy. As an extensive and potentially morbid operation, patient preoperative functional reserve and body composition is an important consideration. Sarcopenia is a risk factor for increased postoperative complications, systemic therapy toxicity, and death solid organ tumors, including RCC. The influence of sarcopenia in RCC patients with tumor thrombus is not well defined. This study evaluates the prognostic ability of sarcopenia regarding surgical outcomes and complications in patients undergoing surgery for RCC with tumor thrombus. Methods: We retrospectively analyzed patients with nonmetastatic RCC and tumor thrombus undergoing radical nephrectomy and tumor thrombectomy. Skeletal muscle index (SMI; cm 2 /m 2 ) was measured on preoperative CT/MRI. Sarcopenia was defined using body mass index- and sex-stratified thresholds optimally fit via a receiver-operating characteristic analysis for survival. Associations between preoperative sarcopenia and overall (OS), cancer-specific survival (CSS), and 90-day major complications were determined using multivariable analysis. Results: 115 patients were analyzed, with median (IQR) age and body mass index of 69 (56-72) and 28.6 kg/m 2 (23.6-32.9), respectively. 96 (83.4%) of the cohort had ccRCC. Sarcopenia was associated with shorter median OS ( P = .0017) and CSS ( P = .0019) in Kaplan-Meier analysis. In multivariable analysis, preoperative sarcopenia was prognostic of shorter OS (HR = 3.38, 95% confidence interval [CI] 1.61-7.09) and CSS (HR = 5.15, 95% CI 1.46-18.18). Notably, 1 unit increases in SMI were associated with improved OS (HR = 0.97, 95% CI 0.94-0.999) but not CSS (HR = 0.95, 95% CI 0.90-1.01). No significant relationship between preoperative sarcopenia and 90-day major surgical complications was observed in this cohort (HR = 2.04, 95% CI 0.65-6.42). Conclusion: Preoperative sarcopenia was associated with decreased OS and CSS in patients surgically managed for nonmetastatic RCC and VTT, however, was not predictive of 90-day major postoperative complications. Body composition analysis has prognostic utility for patients with nonmetastatic RCC and venous tumor thrombus undergoing surgery.

Purpose Timely and effective physical activity (PA) prehabilitation is an evidence-based approach for improving a patient's health status preoperatively. Identifying barriers and facilitators to PA prehabilitation can help inform best practices for exercise prehabilitation program implementation. We explore the barriers and facilitators to PA prehabilitation in patients undergoing nephrectomy. Methods A qualitative exploratory study was conducted by interviewing 20 patients scheduled for nephrectomy. Interviewees were selected via convenience sampling strategy. The interviews were semi-structured and discussed experienced and perceived barriers/facilitators to PA prehabilitation. Interview transcripts were imported to Nvivo 12 for coding and semantic content analysis. A codebook was independently created and collectively validated. Themes of barriers and facilitators were identified and summarized in descriptive findings based on frequency of themes. Results Five relevant themes of barriers to PA prehabilitation emerged: 1) mental factors, 2) personal responsibilities, 3) physical capacity, 4) health conditions, and 5) lack of exercise facilities. Contrarily, facilitators potentially contributing to PA prehabilitation adherence in kidney cancer included 1) holistic health, 2) social and professional support, 3) acknowledgment of health benefits, 4) exercise type and guidance, and 5) Communication channels. Conclusion and key findings Kidney cancer patient's adherence to physical activity prehabilitation is influenced by multiple biopsychosocial barriers and facilitators. Hence, adherence to physical activity prehabilitation requires timely adaptation of health beliefs and behavior embedded in the reported barriers and facilitators. For this reason, prehabilitation strategies should strive to be patient-centered and include health behavioral change theories as underlying frameworks for sustaining patient engagement and self-efficacy.

INTRODUCTION:Low creatinine to cystatin-C ratio (Cr/Cys-C) may be a biomarker for low-muscle mass. Furthermore, low Cr/Cys-C is associated with decreased overall survival (OS), but to date, has not been examined in patients with renal cell carcinoma (RCC). Our objective is to evaluate associations between low Cr/Cys-C ratio and OS and recurrence-free survival (RFS) in patients with RCC treated with nephrectomy. METHODS:We performed a retrospective review of patients with RCC treated with nephrectomy. Patients with end-stage renal disease and less than 1-year follow up were excluded. Cr/Cys-C was dichotomized at the median for the cohort (low vs. high). OS and RFS for patients with high versus low Cr/Cys-C were estimated with the Kaplan-Meier method, and associations with the outcomes of interest were modeled using Cox proportional Hazards models. Associations between Cr/Cys-C and skeletal muscle mass were assessed with correlations and logistic regression. RESULTS:A total of 255 patients were analyzed, with a median age of 64. Median (IQR) Cr/Cys-C was 1 (0.8-1.2). Low Cr/Cys-C was associated with age, female sex, Eastern Cooperative Oncology Group Performance Status ≥1, TNM stage, and tumor size. Kaplan-Meier and Cox regression analysis demonstrated an association between low Cr/Cys-C and decreased OS (HR = 2.97, 95%CI, 1.12-7.90, P =0.029) and RFS (HR = 3.31, 95%CI, 1.26-8.66, P = .015). Furthermore, a low Cr/Cys-C indicated a 2-3 increase in risk of radiographic sarcopenia. CONCLUSIONS:Lower Cr/Cys-C is associated with inferior oncologic outcomes in RCC and, pending validation, may have utility as a serum biomarker for the presence of sarcopenia in patients with RCC treated with nephrectomy.

Abstract Introduction and Objective: Patients with kidney cancer experience higher rates of depression compared with other cancer subtypes. Inflammation has been shown to contribute to depression associated with malignancy. Here, we assess the association between preoperative C-reactive protein (CRP) and major depression, as screened by the eight-item Patient Health Questionnaire (PHQ-8) depression scale, in patients undergoing nephrectomy for nonmetastatic renal cell carcinoma (RCC). Methods: Retrospective review of prospectively administered PHQ-8 surveys in patients who underwent nephrectomy for nonmetastatic RCC was conducted. Patients with available PHQ-8 within 180 days before and after surgery were included. The association of major depressive symptoms on preoperative PHQ-8 and clinical improvement on postoperative survey with patient/tumor characteristics and CRP levels was determined by the generalized chi-square test for categorical variables and analysis of variance for continuous variables. Multivariable logistic regression was used to analyze variables associated with major depression on PHQ-8 and postoperative survey improvement. Results: Two hundred forty-five patients were analyzed. Most were male (66%). Median age and body mass index were 65 and 28.9 kg/m2, respectively. 64.5% of patients were White, and 29.0% were Black. 30.2% had an elevated CRP (≥10 mg/L). 45 (18.4%) patients screened positive for major depressive symptoms on PHQ-8 (≥10 points). Patients with elevated CRP were more likely to have positive preoperative depression screening (odds ratio [OR] 2.66, 95% CI 1.08–6.52, P = .033) but had higher probability of demonstrating meaningful change on PHQ-8 after nephrectomy (OR 3.50, 95% CI 1.04–11.85, P = .044). Conclusion: In nonmetastatic RCC, patients with elevated preoperative CRP had higher scoring for major depressive symptoms on PHQ-8 and were more likely to demonstrate clinical improvement in depressive symptomatology after nephrectomy.

BackgroundBlack patients face disparities in cancer outcomes. Additionally, Black patients are more likely to be undertreated and underrepresented in clinical trials. The recent recommendation to remove race from the estimated glomerular filtration rate (eGFR) results in lower eGFR values for Black patients. The ramifications of this decision, both intended and unintended, are still being elucidated in the medical community. Here, the authors analyze the removal of race from eGFR for Black patients with cancer, specifically with respect to clinical trial eligibility. MethodsIn a cohort of self-identified Black patients who underwent nephrectomy at a tertiary referral center from 2009 to 2021 (n = 459), eGFR was calculated with and without race in commonly used equations (Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] and Modification of Diet in Renal Disease [MDRD]). The distribution of patients and changes within chronic kidney disease stages with different equations was considered. Theoretical exclusion at commonly observed clinical trial eGFR points was then simulated on the basis of the utilization of the race coefficient. ResultsThe median eGFR from CKD-EPI was significantly higher with race (76 ml/min/1.73 m(2)) than without race (66 ml/min/1.73 m(2); p < .0001). The median eGFR from MDRD was significantly higher with race (71.0 ml/min/1.73 m(2)) than without race (58 ml/min/1.73 m(2); p < .0001). Observing results in the context of common clinical trial cutoff points, the authors found that 13%-22%, 6%-12%, and 2%-3% more Black patients would fall under common clinical trial cutoffs of 60, 45, and 30 ml/min, respectively, depending on the equation used. A subanalysis of stage III-IV patients only was similar. ConclusionsRace-free renal function equations may inadvertently result in increased exclusion of Black patients from clinical trials. This is especially concerning because of the underrepresentation and undertreatment that Black patients already experience. Plain Language Summary Black patients experience worse oncologic outcomes and are underrepresented in clinical trials.Kidney function, as estimated by glomerular filtration rate equations, is a factor in who can and cannot be in a clinical trial.Race is a variable in some of these equations.For Black patients, removing race from these equations leads to the calculation of lower kidney function.Lower estimated kidney function may result in more black patients being excluded from clinical trials.The inclusion of all races in clinical trials is important for offering best care to everyone and for making results from clinical trials applicable to everyone.

611 Background: Race is no longer recommended in estimated glomerular filtration rate (eGFR) equations. The resulting lower eGFR may positively impact black patients, such as with earlier nephrology referral. However, the impact of race-free equations on black oncology patients–a cohort more likely to experience inferior cancer outcomes and underrepresentation in clinical trials–has not been fully examined. Here, we analyze removal of race from eGFR in black patients with cancer, specifically with regards to clinical trial eligibility. Methods: Self-identified black patients undergoing nephrectomy at a referral center from 2009-2021 were identified. Patients with end-stage renal disease were excluded. Using preoperative creatinine, height, and weight, eGFR was calculated with the Chronic Kidney Disease Epidemiology Collaboration creatinine equation with and without race (CKD-EPI-WithRace; CKD-EPI-WithoutRace, respectively), and the Modification of Diet in Renal Disease equation with and without race (MDRD-WithRace; MDRD-WithoutRace, respectively). Distribution of patients and changes within CKD stages with different equations was considered. Theoretical exclusion at commonly observed clinical trial eGFR points was then simulated based on utilization of the race coefficient. Subgroup analysis was completed on patients with stage III-IV disease only. Results: 459 self-identified black patients that underwent nephrectomy at our institution were identified, 135 of which had stage III-IV disease. On average, eGFR decreased around 10-13ml/min/1.73m2 with removal of the race coefficient (Table). 13-22%, 6-12%, and 2-3% more black patients would fall under common clinical trial cutoffs of 60, 45, or 30ml/min cutoffs, respectively, depending on the equation used (Table). Subanalysis of stage III-IV patients only were similar. Conclusions: Race free renal function equations may inadvertently result in increased exclusion of black patients from clinical trials. [Table: see text]

Introduction: A universally accepted model for preoperative surgical risk stratification in localized RCC patients undergoing nephrec-tomy is currently lacking. Both the evaluation of body composition and nutritional status has demonstrated prognostic value for patients with cancer. This study aims to investigate the potential associations between sarcopenia and hypoalbuminemia and survival outcomes in patients with localized kidney cancer treated with partial or radical nephrectomy. Materials and Methods: We retrospectively analyzed 473 patients with localized RCC managed with radical and partial nephrectomy. Skeletal muscle index (SMI) was measured from preoperative CT and MRI. Sarcopenic criteria were created using BMI-and sex-stratified thresholds. Relationships between sarcopenia and hypoalbuminemia (Albumin < 3.5 g/dL) with overall (OS), recurrence-free (RFS), and cancer-specific survival (CSS) were determined using multivariable and Kaplan-Meier analysis. Results: Of the 473 patients, 42.5% were sarcopenic and 24.5% had hypoalbuminemia. Sarcopenia was significantly associated with shorter OS (HR=1.51, 95% CI 1.07-2.13), however, was nonsignificant in the RFS (HR =1.33, 95% CI 0.88-2.03) and CSS (HR=1.66, 95% CI 0.96-2.87) models. Hypoalbuminemia predicted shorter OS (HR=1.76, 95% CI 1.22-2.55), RFS (HR=1.86, 95% CI 1.19-2.89), and CSS (HR=1.82, 95% CI 1.03-3.22). Patients were then stratified into low, medium, and high-risk groups based on the severity of sarcopenia and hypoalbuminemia. Risk groups demonstrated an increasing association with shorter OS (all p < 0.05). Reduced RFS was observed in the medium risk-hypoalbuminemia (HR=2.18, 95% CI 1.16-4.09) and high-risk groups (HR=2.42, 95% CI 1.34-4.39). Shorter CSS was observed in the medium risk-hypoalbuminemia (HR=2.31, 95% CI 1.00-5.30) and high-risk groups (HR=2.98, 95% CI 1.34-6.61). Conclusion: Localized RCC patients with combined preoperative sarcopenia and hypoalbuminemia displayed a two to a three-fold reduction in OS, RFS, and CSS after nephrectomy. These data have implications for guiding prognostication and treatment election in local-ized RCC patients undergoing extirpative surgery. (C) 2022 Elsevier Inc. All rights reserved.

658 Background: Patients with cancer experience depression at higher rates, which is associated with worse outcomes and quality of life. In renal cell carcinoma (RCC) specifically, depression is particularly prevalent. Aside from the emotional distress of a cancer diagnosis, a biologic basis for cancer associated depression is inflammation, which is highly associated with RCC as well as worse outcomes. Here, we aim to assess the association between inflammation and major depression, measured by a score of 10+ on the Patient Health Questionnaire (PHQ-8), in patients undergoing nephrectomy for nonmetastatic RCC. Methods: A retrospective review of prospectively administered PHQ-8 surveys in patients that underwent nephrectomy for nonmetastatic RCC was conducted. Patients with available preoperative PHQ-8 within 180 days before surgery were included. Association of major depression on PHQ-8 with patient/tumor characteristics were determined by Generalized chi-square test or Fisher’s exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. Multivariable logistic regression was used to determine variables significantly associated with major depression on PHQ-8, including pre-operative C-Reactive Protein (CRP) independently and combined with American Joint Committee on Cancer (AJCC) staging for RCC. Results: 224 patients were analyzed, with 67% being male. Median age and BMI was 64 and 29.0, respectively. 65.2% of patients were white, and 28.6% were black. Histologically, most patients had clear cell RCC (67.4%). AJCC staging was 52.2% stage I, 5.36% stage II, and 42.41% stage III. 30.4% had an elevated CRP (>10mg/L). Median PHQ-8 score was 4, with 42 (18.8%) of patients screening positive for major depression on PHQ-8 (10+). Multivariable regression models showed elevated CRP alone (OR 2.74, 95% CI 1.02-7.40, p=0.047) and in-combination with AJCC stage I-II (OR=8.13, 95% CI 1.99-33.27, p=0.004) and III (OR=4.82, CI 1.11-20.88, p=0.035) as a predictor of major depression on PHQ-8. Conclusions: In this study of patients with nonmetastatic RCC, elevated CRP (>10mg/L) was an independent predictor of major depression on PHQ-8. [Table: see text]

617 Background: In renal cell carcinoma (RCC) and other solid organ malignancies, sarcopenia has been associated with decreased survival and increased perioperative complications. Traditional body composition analysis is an expensive and time extensive process. As a modifiable risk factor, more clinic friendly methods to identify patients with low muscle composition is of interest. Linear segmentation on routine imaging has been proposed as a fast, reliable and reproducible alternative. This study assesses the prognostic ability of linear segmentation in patients with nonmetastatic RCC. Methods: Patients that underwent nephrectomy for nonmetastatic RCC from 2005-2021 at an academic referral center were identified. Linear segmentation of the bilateral psoas/paraspinal muscles was completed on preoperative imaging obtained within 60 days of surgery. Cox proportional-hazards analysis was used to determine association between total muscle index and overall survival. Results: 532 (388 clear cell) patients were analyzed and a median total muscle index was 28.6 (25.8-32.5) for women and 33.3 (29.1-36.9) for men. As a binary variable, lower total muscle index was significantly associated with decreased survival in both the full (HR=1.96, 95% CI 1.32-2.90, p<0.001) and clear cell only cohorts (HR=1.78, 95% CI 1.08-2.75, p=0.022). As a continuous variable, unit increases in total muscle index were significantly associated with improved survival in the full cohort (HR=0.95, 95% CI 0.92-0.99, p=0.006) and the clear cell only cohort (HR=0.95, 95% CI 0.92-0.99, p=0.016). Conclusions: Assessment of muscle composition via linear segmentation on routinely obtained preoperative imaging is a clinically feasible technique with prognostic utility in patients with localized RCC. In this cohort of patients with nonmetastatic RCC, linear segmentation demonstrated significant associations with overall survival as a binary and continuous variable. This simplified technique may allow for routine inclusion of body composition into clinical decision making. [Table: see text]

You have accessJournal of UrologyCME1 Apr 2023MP12-03 IMPLICATIONS OF RACE FREE RENAL FUNCTION EQUATIONS ON BLACK PATIENTS WITH RENAL CELL CARCINOMA Benjamin N. Schmeusser, Arnold R. Palacios, Eric Midenberg, Reza Nabavizadeh, Adil Ali, Dattatraya H. Patil, R. Donald Harvey, Janetta Bryksin, Michael J. Connor, Kenneth Ogan, Mehmet A. Bilen, and Viraj A. Master Benjamin N. SchmeusserBenjamin N. Schmeusser More articles by this author , Arnold R. PalaciosArnold R. Palacios More articles by this author , Eric MidenbergEric Midenberg More articles by this author , Reza NabavizadehReza Nabavizadeh More articles by this author , Adil AliAdil Ali More articles by this author , Dattatraya H. PatilDattatraya H. Patil More articles by this author , R. Donald HarveyR. Donald Harvey More articles by this author , Janetta BryksinJanetta Bryksin More articles by this author , Michael J. ConnorMichael J. Connor More articles by this author , Kenneth OganKenneth Ogan More articles by this author , Mehmet A. BilenMehmet A. Bilen More articles by this author , and Viraj A. MasterViraj A. Master More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003227.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Race is no longer recommended in estimated glomerular filtration rate (eGFR) equations. The resulting lower eGFR may positively impact black patients, such as with earlier nephrology referral and renal transplant eligibility. The impact of race-free equations on black patients with renal cell carcinoma (RCC)–a cohort more likely to experience inferior cancer outcomes–has not been fully examined. Renal function assessment is important in patients with RCC given the recommendations of nephron sparing approaches (i.e. partial nephrectomy [PN]) over radical (RN) in patients with CKDIIIa or estimated post-nephrectomy eGFR of <45 mL/min/1.73m2. Here, we analyze removal of race from eGFR in black patients with RCC and consider the impact of this change in the context of RCC treatment. METHODS: Self-identified black patients undergoing nephrectomy at an academic referral center from 2009-2021 were identified. Patients with end-stage renal disease were excluded. Using preoperative creatinine, height, and weight, eGFR was calculated with the Chronic Kidney Disease Epidemiology Collaboration creatinine equation with and without race (CKD-EPI-WithRace; CKD-EPI-WithoutRace, respectively), and the Modification of Diet in Renal Disease equation with and without race (MDRD-WithRace; MDRD-WithoutRace, respectively). Distribution of patients and changes within CKD stages with different equations was considered. Subgroup analysis was completed on patients with stage III-IV disease only. RESULTS: 459 self-identified black patients that underwent nephrectomy at our institution were identified, 135 of which had stage III-IV disease. eGFR decreased around 10-13ml/min/1.73m2 with removal of the race coefficient. 13-22%, 6-12%, and 2-3% more black patients would fall under common CKD cutoffs of 60, 45, or 30ml/min/1.73m2, respectively, depending on the equation used (Figure 1). Subanalysis of stage III-IV patients only were similar. CONCLUSIONS: Race free renal function equations may result in significantly more black patients being encouraged to undergo nephron sparing treatments. Source of Funding: We gratefully acknowledge the support of the John Robinson Family Foundation and the Chris Churchill Family Foundation © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e133 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benjamin N. Schmeusser More articles by this author Arnold R. Palacios More articles by this author Eric Midenberg More articles by this author Reza Nabavizadeh More articles by this author Adil Ali More articles by this author Dattatraya H. Patil More articles by this author R. Donald Harvey More articles by this author Janetta Bryksin More articles by this author Michael J. Connor More articles by this author Kenneth Ogan More articles by this author Mehmet A. Bilen More articles by this author Viraj A. Master More articles by this author Expand All Advertisement PDF downloadLoading ...

Background: Preoperative frailty has been associated with adverse postoperative outcomes. Additionally, low testosterone has been associated with physical frailty and cognitive decline. However, the impact of simultaneous frailty and low testosterone on surgical outcomes is understudied. Methods: Preoperative frailty status and testosterone levels were obtained in patients undergoing a diverse range of surgical procedures. Preoperative frailty was evaluated independently and in combination with testosterone through the creation of composite risk groups. Relationships between preoperative frailty and composite risk groups with overall survival were determined using Kaplan-Meier and logistic regression analyses. Bivariate analysiswas used to determine the associations between frailty and testosterone status on postoperative complications, length of hospital stay, and readmission rates. Results: Median age of the cohort was 63 years, and the median follow-up time was 105 weeks. Thirty-one patients (23%) were frail, and 36 (27%) had low free testosterone. Bivariate analysis demonstrated a statistically significant relationship between preoperative frailty and overall survival (P=044). In multivariate analysis, coexisting frailty and low free testosterone were significantly associated with decreased overall survival (hazard ratio 4.93, 95% confidence interval, 1.68-14.46, P=.004). Conclusion: We observed preoperative frailty, both independently and in combination with low free testosterone levels, to be significantly associated with decreased overall survival across various surgical procedures. Personalizing the surgical risk assessment through the incorporation of preoperative frailty and testosterone status may serve to improve the prognostication of patients undergoing major surgery. (C) 2021 The Authors. Published by Elsevier Inc.

Background:Quantifying grit with the Short Grit Scale (Grit-S) has shown ability to predict success in various academic and professional domains. Grit has yet to be analyzed in patients with cancer.Methods:This study is a longitudinal analysis of prospectively distributed Grit-S surveys to patients undergoing radical or partial nephrectomy. Patients who completed a preoperative Grit-S survey with confirmed renal cell carcinoma (RCC) were included in the analysis. The relationship between preoperative grit scores and overall survival (OS) was determined using Cox proportional-hazard models and Kaplan-Meier analysis.Results:A total of 323 patients with RCC that completed the Grit-S survey prior to nephrectomy were included in the study. Median Grit score was 3.9. Most patients were male (67.5%), White (69.3%), and greater than 60 years old (57.0%) with a median age of 62 at the time of surgery. Patients scoring above or below the median grit score had similar baseline characteristics. As a binary variable, lower preoperative grit was significantly associated with shorter OS [hazard ratio (HR) =2.02, 95% confidence interval (CI): 1.12-3.63, P=0.019] on multivariable analysis. Unit changes in grit were not significantly associated with OS (HR =0.77, 95% CI: 0.53-1.14, P=0.193).Conclusions:Lower grit scores may predict decreased OS in RCC patients undergoing nephrectomy. The Grit-S survey may have utility in preoperative evaluation. Further research assessing grit in other malignancies and how to psychologically optimize patients prior to surgery are needed.