The Detrimental Effect of Metabolic Syndrome on Long-term Renal Function in Patients Undergoing Elective Partial Nephrectomy for Small Renal Masses

Background and objective

Metabolic syndrome (MetS) is a clinical condition associated with higher rates of overall and cardiovascular mortality. There is scarce evidence regarding the impact of MetS on surgical and functional outcomes for patients undergoing partial nephrectomy (PN) for clinically localized small renal masses (SRMs).

Methods

We analyzed data from a prospectively maintained institutional database for 690 patients with cT1a renal cancer undergoing PN between 2000 and 2023 at a tertiary referral center. MetS was defined according to international guidelines. Cumulative incidence curves were used to estimate the 5-yr risk of stage IIIB-V chronic kidney disease (CKD) stage and other-cause mortality (OCM). Multivariable regression models were used to analyze the impact of MetS on the risk of complications, acute kidney injury (AKI), stage IIIB-V CKD, and OCM.

Key findings and limitations

Overall, 10% of the PN cohort had MetS. The MetS group was older (median age 70 yr, interquartile range [IQR] 65-74 vs 61 yr, IQR 50-69; p < 0.001) and had worse preoperative kidney function (median estimated glomerular filtration rate 65 [IQR 62-81] vs 88 [IQR 69-98] ml/min/1.73 m2; p < 0.001) than the group without MetS. The MetS group had higher incidence of complications (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.05-3.08; p = 0.03) and postoperative AKI (OR 3.17, 95% CI 1.54-6.41; p = 0.001). The 5-yr risk of stage IIIB-V CKD (45% vs 7.2%; hazard ratio [HR] 2.34, 95% CI 1.27-4.30; p = 0.006) and OCM (14% vs 3.5%; HR 3.00, 95% CI 1.06-8.55; p = 0.039) were also higher in the MetS group. The main limitations are the extended accrual time and unmeasured confounders that could potentially affect outcomes.

Conclusions and clinical implications

Patients with MetS had worse postoperative, functional, and survival outcomes after SRM surgery in comparison to patients without MetS. Multidisciplinary care could help in reducing the preoperative metabolic burden in these patients. Further research should explore if alternative approaches (eg, surveillance or focal therapy) could minimize postoperative comorbidities and protect long-term renal function in this population.

Patient summary

Patients with a condition called metabolic syndrome who have part of their kidney removed for small kidney tumors are at higher risk of complications and long-term kidney issues. Patient care from a multidisciplinary team could help in reducing the metabolic burden before surgery. Further research is needed to explore if less invasive treatment options could reduce these risks.

Metabolic Syndrome (MetS), Systemic Inflammatory Response Syndrome (SIRS), and Frailty: Is There any Room for Good Outcome in the Elderly Undergoing Emergency Surgery?

Background

Patients with MetS or SIRS experience higher rates of mortality and morbidity, across both cardiac and noncardiac surgery. Frailty assessment has acquired increasing importance in recent years as it predisposes elderly patients to a worse outcome. The aim of our study was to investigate the influence of MetS, SIRS, and with or without frailty on elderly patients undergoing emergency surgical procedures.

Methods

We analyzed data of all patients with nonmalignant diseases requiring an emergency surgical procedure from January 2017 to December 2020. The occurrence of MetS was identified using modified definition criteria used by the NCEP-ATP III Expert Panel: obesity, hypertension, diabetes, or if medication for high triglycerides or for low HDL cholesterol was taken. Systemic inflammatory response syndrome (SIRS) was evaluated according to the original consensus study (Sepsis-1). The frailty profile was investigated by the 5-modified Frailty Index (5-mFI) and the Emergency Surgery Frailty Index (EmSFI). Postoperative complications have been reported and categorized according to the Clavien-Dindo (C-D) classification system. Morbidity and mortality have been mainly considered as the 30-day standard period definition.

Results

Of the 2,318 patients included in this study, 1,010 (43.6%) fulfilled the criteria for MetS (MetsG group). Both 5-Items score and EmsFI showed greater fragility in patients with MetS. All patients with MetS showed more frequently a CACI index greater than 6. The occurrence of SIRS was higher in MetSG. LOS was longer in patients with MetS (MetSG 11.4 ± 12 days vs. n-MetSG 10.5 ± 10.2 days, p = 0.046). MetSG has a significantly higher rate of morbidity (353 (35.%) vs. 385 (29.4%), p = 0.005). The mortality rate in patients with MetS (98/1010, 10%) was similar to that in patients without it (129/1308, 10%). Considering patients with MetS who developed SIRS and those who had frailty or both, the occurrence of these conditions was associated with a higher rate of morbidity and mortality.

Conclusion

Impact of MetS and SIRS on elderly surgical patient outcomes has yet to be fully elucidated. The present study showed a 43.6% incidence of MetS in the elderly population. In conclusion, age per se should be not considered anymore as the main variable to estimate patient outcomes, while MetS and Frailty should have always a pivotal role.

Obesity and biochemical recurrence in clinically localised prostate cancer: a systematic review and meta-analysis of 86,490 patients

BACKGROUND

The association of obesity with biochemical recurrence (BCR) after treatment of clinically localised prostate cancer (PC) shows inconsistent results. Our aim was to systematically review all evidence evaluating obesity as a prognostic factor for BCR.

METHODS

We searched PubMed, Web of Science and Scopus, from inception to June 1, 2021. Cohort studies reporting BCR among PC patients stratified by body mass index (BMI) were included. To assess the quality of the selected studies, we used the Newcastle-Ottawa scale (NOS). Risk of BCR among obese patients (BMI ≥ 30 kg/m²) was compared with normal weight (BMI < 25), pooling individual hazard ratios (HR) in random-effect meta-analysis. Associations for continuous BMI per 5 kg/m² were also calculated. Subgroup analyses were conducted to assess reasons for heterogeneity and causal criteria were formally evaluated.

RESULTS

We identified 46 cohort studies including 86,490 PC patients. A total of 14,719 (17.1%) patients developed BCR. There was no consistent definition of BCR. Obesity was associated with BCR (HR: 1.25, 95% CI: 1.11-1.39, I²: 70.3%), and there was a 10% increase (95% CI: 4-15%, I²: 66.3%) in BCR per 5 kg/m² increase in BMI. The heterogeneity was high but decreased in the subgroup of highest-quality NOS score and when the BMI was measured by the researchers (I²: 0.0%). The association was consistent in patients receiving radical prostatectomy but not in patients receiving other therapies.

CONCLUSIONS

Obesity showed a moderate, consistent relationship with biochemical recurrence after radical prostatectomy. Measurement of BMI and BCR was variable, highlighting the need for standardised clinical guidelines. Preventive weight control programs may have a role in reducing BCR for clinically localised PC patients.

Prognostic significance of diabetes mellitus and dyslipidemia in men receiving androgen-deprivation therapy for metastatic prostate cancer

Objective

The outcome of the androgen-deprivation therapy (ADT) may be affected by metabolic diseases such as diabetes mellitus (DM) and dyslipidemia and/or by their treatments. We aimed to evaluate the prognostic impact of these disorders and corresponding medications in Japanese men treated with ADT for prostate cancer.

Methods

This study retrospectively included 121 patients with metastatic prostate cancer who were treated with primary ADT at our hospital between 2001 and 2013. All patients received primary ADT with castration and/or an antiandrogen agent (bicalutamide or flutamide). Associations between clinicopathological factors, metabolic disease profiles, medication use, and prognosis (progression-free survival [PFS] and overall survival [OS]) were evaluated by univariate and multivariate analysis.

Results

The median follow-up time was 54.9 months, and the median PFS and OS were 23.9 months and 73.0 months, respectively. High serum glucose levels at baseline (hazard ratio [HR], 95% confidence interval [CI]: 2.12, 1.16–3.76; P = 0.015), and concurrent DM (HR, 95% CI: 2.07, 1.06–3.94; P = 0.034) were significantly associated with poorer OS after adjustment for age, prostate-specific antigen levels at diagnosis, Gleason score, and clinical stage. Treatment with sulfonylurea drugs was significantly associated with a reduced risk of disease progression in men with DM (HR, 95% CI: 0.36, 0.12–0.90; P = 0.028).

Conclusions

Impaired glucose tolerance and treatment with sulfonylureas have prognostic significance in prostate cancer. These findings demonstrate the importance of managing DM during ADT and point to a possible favorable effect of sulfonylureas on prostate cancer.

Impact of Body Composition on the Risk of Hepatocellular Carcinoma Recurrence After Liver Transplantation

BACKGROUND

Body composition parameters are reported to influence the risk of hepatocellular carcinoma (HCC) recurrence after liver resection, yet data on patients undergoing liver transplantation are scarce. The aim of this study was to evaluate the impact of the amount of abdominal adipose tissue and skeletal muscles on the risk of HCC recurrence after liver transplantation.

METHODS

This was a retrospective observational study performed on 77 HCC patients after liver transplantation. Subcutaneous fat area (SFA), visceral fat area, psoas muscle area and total skeletal muscle area were assessed on computed tomography on the level of L3 vertebra and divided by square meters of patient height. The primary outcome measure was five-year recurrence-free survival.

RESULTS

Recurrence-free survival in the entire cohort was 95.7%, 90.8%, and 86.5% after one, three, and five years post-transplantation, respectively. SFA was significantly associated with the risk of HCC recurrence (p = 0.013), whereas no significant effects were found for visceral fat and skeletal muscle indices. The optimal cut-off for SFA for prediction of recurrence was 71.5 cm²/m². Patients with SFA < 71.5 cm²/m² and ≥71.5 cm²/m² exhibited five-year recurrence-free survival of 96.0% and 55.4%, respectively (p = 0.001).

CONCLUSIONS

Excessive amount of subcutaneous adipose tissue is a risk factor for HCC recurrence after liver transplantation and may be considered in patient selection process.

Serum lipids might improve prostate-specific antigen sensitivity in patients undergoing transrectal ultrasonography-guided biopsy for suspected prostate cancer: A pilot study

Objectives: To investigate the potential use of body mass index (BMI) and serum lipids in improving prostate-specific antigen (PSA) sensitivity in patients undergoing biopsy for suspicion of prostate cancer, as there is an established relationship between metabolic syndrome, obesity and serum lipids with prostate cancer.

Patients and methods: A pilot study was conducted in a tertiary referral centre between June 2016 and August 2017 of patients undergoing transrectal ultrasonography (TRUS)-guided biopsy. After the result of TRUS-biopsy, the first 50 patients diagnosed with prostate cancer (study group) and those with no prostate cancer (control group) were enrolled. BMI, serum PSA level, fasting blood sugar and lipid profile (e.g. cholesterol, triglycerides, low-density lipoprotein [LDL] and high-density lipoprotein [HDL]), were compared between the groups.

Results: Higher BMI, cholesterol, LDL and lower HDL together with PSA were significantly associated with a positive biopsy. On multivariate analysis, LDL (odds ratio [OR] 5.3, 95% confidence interval [CI] 1.2–24.9; P = 0.03) and total PSA level (OR 12.9, 95% CI 4.7–35; P < 0.001) were independent predictors of a positive biopsy. A combination of LDL <80 mg/dL and PSA level <26 ng/mL threshold values determined by receiver operating characteristic curve analysis, had a sensitivity and specificity of 94% and 28%, respectively; whilst, the negative (NPV) and positive predictive values were 82.4% and 56.6%, respectively. The sensitivity and NPV of the combination was significantly higher than that of PSA level alone (94% vs 72% and 82.4% vs 75%, respectively; P < 0.001).

Conclusions: Serum lipids might have a role in the diagnosis of prostate cancer and could be used as an adjunct to PSA measurement to improve sensitivity and avoid unnecessary biopsies.

Abbreviations: AUC: area under the curve; BMI: body mass index; FBS: fasting blood sugar; HDL: high-density lipoprotein; LDL: low-density lipoprotein; LOX-1: lectin-like oxidised LDL receptor-1; OR: odds ratio; ROC: receiver operating characteristic; RP: radical prostatectomy; TG: triglyceride

In-Hospital Mortality and Post-Surgical Complications Among Cancer Patients with Metabolic Syndrome

BACKGROUND

Metabolic syndrome (MetS) is an important etiologic and prognostic factor for cancer, but few studies have assessed hospitalization outcomes among patients with both conditions.

METHODS

Data was obtained from the Healthcare Cost and Utilization project Nationwide Inpatient Sample (HCUP-NIS). Study variables were assessed using ICD-9 codes on adults aged 40 years and over admitted to a US hospital between 2007 and 2011 with primary diagnosis of either breast, colorectal, or prostate cancer. We examined in-hospital mortality, post-surgical complications, and discharge disposition among cancer patients with MetS and compared with non-MetS patients.

RESULTS

Hospitalized breast (OR: 0.31, 95% CI: 0.20-0.46), colorectal (OR: 0.41, 95% CI: 0.35-0.49), and prostate (OR: 0.28, 95% CI: 0.16-0.49) cancer patients with MetS had significantly reduced odds of in-hospital mortality. The odds of post-surgical complications among breast (OR: 1.20, 95% CI: 1.03-1.39) and prostate (OR: 1.22, 95% CI: 1.09-1.37) cancer patients with MetS were higher, but lower by 7% among colorectal cancer patients with MetS. Additionally, breast (OR: 1.21, 95% CI: 1.11-1.32) and colorectal (OR: 1.06, 95% CI: 1.01-1.11) cancer patients with MetS had significantly higher odds for discharge to a skilled nursing facility compared with those without MetS, but this was not statistically significant among prostate cancer patients.

CONCLUSIONS

Adverse health outcomes were significantly higher among hospitalized patients with a primary diagnosis of cancer and MetS. Future studies are needed to identify clinical strategies for detecting and managing patients with MetS to reduce the likelihood of poor inpatient outcomes.

Clinical factors affecting perioperative outcomes in robot-assisted radical prostatectomy

The present study investigated clinical factors affecting perioperative outcomes in robot-assisted radical prostatectomy (RARP). The study included 625 Japanese cases treated with RARP between 2009 and 2017. The association between clinical factors (age, overweight status, prostate volume, clinical T-stage, nerve sparing, lympho-node dissection, and the number of experienced cases) and perioperative outcomes (operation time, estimated blood loss, catheterization duration, and perioperative complication) were analyzed. Results revealed that overweight status, prostate volume, lymph-node dissection, and the number of experienced cases were associated with operation time. For estimated blood loss, the identified risk factors were overweight status, prostate volume, nerve sparing, lymph-node dissection, and the number of experienced cases. Lymph-node dissection and the number of experienced cases were also associated with catheterization duration. Additionally, only lymph-node dissection was associated with increased perioperative complication. Taken together, the present study identified several clinical factors affecting perioperative outcomes in RARP. This information may help surgeons to estimate perioperative outcomes as well as to inform patients.

Obesity and prostate cancer

PURPOSE OF REVIEW

To investigate the association between obesity and prostate cancer (PCa).

RECENT FINDINGS

Obesity has been proposed to be involved in the pathogenesis of PCa through different biological mechanisms that include deregulation of the insulin axis, sex hormone secretion, adipokines signaling, and oxidative stress. Hypertrophic peritumoral adipocytes may also facilitate the local spread of PCa through the chemo-attraction of tumor cells. Clinical studies demonstrate that obesity might have clinical implications also in disease detection and management. Obese men have been shown to be less likely to be diagnosed with early-stage disease. Moreover, they are at increased risk of experiencing upgrading and upstaging when managed with active surveillance. However, the association between obesity and the risk of PCa recurrence and mortality after radical treatment is still debated.

SUMMARY

Obesity may facilitate the development and progression of PCa trough different biologic mechanisms that may pose obese men at higher risk of advanced and high-grade disease. However, the association between obesity and long-term oncologic outcome after radical treatments appears unclear.

Does metabolic syndrome predict surgical complications? A protocol for a systematic review and meta-analysis

BACKGROUND

Metabolic syndrome (MetS) is defined by an accumulation of risk factors that include cardiovascular disease, diabetes, chronic high blood pressure, obesity, and hypercholesterolaemia which results in an increased risk of developing serious chronic diseases. MetS is widespread as it is estimated to affect up to 30% of the global population. For people with MetS who undergo surgery, an emerging body of literature points to significantly poorer postoperative outcomes compared with non-affected populations. Surgical patients with MetS are at significantly higher risk of a range of adverse outcomes including death, morbid cardiovascular events, coma, stroke, renal failure, myocardial infarction, and surgical site infections. Increased complication rates result in prolonged hospital stays, a greater need for post-hospitalisation care, and reduced effectiveness of surgical interventions.

METHODS/DESIGN

We will search the following electronic bibliographic databases: MEDLINE, EMBASE, ScienceDirect, and CINAHL, and the reference lists of included articles. We will also search for unpublished literature. Two authors will screen titles and abstract information independently and select studies according to established inclusion and exclusion criteria. Data will be extracted by the study investigators using Review Manager 5 and will include information on demographics, incidence, prevalence, and outcome variables. Subgroup analysis and sensitivity analysis will be performed to assess the heterogeneity of included studies. Meta-analysis will also be carried out if appropriate study groups are identified. A descriptive narrative for statistical data will also be provided to highlight findings of the systematic review and meta-analysis.

DISCUSSION

This study will report and summarise adverse outcomes among adult patients with MetS undergoing surgery across a range of surgical specialties. Developing insights into outcomes of this population of interest is necessary to develop guidelines towards better management of surgical patients with metabolic syndrome.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016051071.