Correspondence
Re: ‘The impact of chronic kidney disease on postoperative outcome following colorectal cancer surgery’ doi:10.1111/codi.12747
Dear Editor, We read with interest the article by Currie et al. [1] indicating the negative impact of chronic kidney disease (CKD) on noncancer-associated survival following surgical resection for colorectal cancer. The authors are reportedly the first to explore the effect of CKD on short- and long-term outcomes following surgery for colorectal cancer. In doing so they provide important data for surgeons to identify potential high-risk patients and institute interventional strategies prior to surgery to improve potential outcomes. In their study, 708 patients with nonmetastatic colorectal cancer undergoing R0 surgical resection were divided into two study groups, those with CKD stage 0–2 (582) and with CKD stage 3–4 (126) disease, and compared for differences in postoperative complications and survival. Using a multivariate logistic regression model CKD stage 3–4 was an independent factor for earlier noncancer-related death but not for overall or disease-free survival. In addition, patients with CKD stage 3–4 were noted to have more cardiovascular complications. The authors concluded that identification of CKD in routine preoperative assessment of colorectal cancer surgery may assist in more balanced decisionmaking, particularly in an increasingly older and comorbid patient group. Their study acknowledges several limitations in the discussion, and we would like to propose some other factors that may be of interest when considering the robustness and validity of their findings. It is readily apparent from the data that those with CKD stage 3– 4 are older, have greater cardiovascular and diabetic comorbidity and poorer tumour pathological characteristics including T stage and degree of differentiation. If CKD were not mentioned the reader might assume that the cause of early mortality is a combination of hypertension and/or diabetes. This assumption can have important consequences for the results, as CKD 3–4 may be a surrogate marker of the severity of any preoperative cardiovascular disease such as hypertension or of diabetic nephropathy, which may be the reason for greater cardiovascular complications following surgery rather than CKD per se. Furthermore can we then reliably extrapolate these results
to patients with advanced CKD, due for example to Fabry disease, glomerular nephritis, polycystic kidney disease or IgA nephropathy? While cardiovascular complications are more severe in CKD stage 3–4 than stage 0–2, would the findings have been the same if cardiovascular disease and/or diabetes had been compared in patients with and without CKD? Despite the adjusted multivariate model demonstrating that CKD is an independent factor for the outcome in the study, it does not distinguish between cause and effect. A prospective study looking at treatments to improve the glomerular filtration rate before surgery and its effects on the outcome is clearly warranted.
S. G. Farid, N. Shah, I. Wijetunga and D. Longbotham Department of Surgery, St James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK E-mail: [email protected] Received 7 June 2014; accepted 15 June 2014; Accepted Article online 12 August 2014
Reference 1 Currie A, Malietzis G, Askari A et al. The impact of chronic kidney disease on postoperative outcome following colorectal cancer surgery. Colorectal Dis 2014; 69: 879–85.
Improving timely detection and recording of colorectal peritoneal metastases doi:10.1111/codi.12794
Dear Sir, Dr Segelman and colleagues (Colorectal Dis 2014; 16: 359–367) have provided us with a practical tool that may predict and allow for the early detection and treatment of metachronous colorectal peritoneal metastases [1]. It is now widely accepted that surgical intervention in the form of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in appropriately selected patients with resectable peritoneal disease can improve outcome. Furthermore, intervention when disease volume is low is associated with a greater likelihood of complete resection and improved survival. This predictive tool may help us to identify patients with peritoneal metastases at an early stage when surgical intervention may be maximally beneficial. A focus on the early detection of recurrent disease also serves to raise our awareness further of
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 1019–1023
1019
Re: ‘The impact of chronic kidney disease on postoperative outcome following colorectal cancer surgery’ doi:10.1111/codi.12747
Dear Editor, We read with interest the article by Currie et al. [1] indicating the negative impact of chronic kidney disease (CKD) on noncancer-associated survival following surgical resection for colorectal cancer. The authors are reportedly the first to explore the effect of CKD on short- and long-term outcomes following surgery for colorectal cancer. In doing so they provide important data for surgeons to identify potential high-risk patients and institute interventional strategies prior to surgery to improve potential outcomes. In their study, 708 patients with nonmetastatic colorectal cancer undergoing R0 surgical resection were divided into two study groups, those with CKD stage 0–2 (582) and with CKD stage 3–4 (126) disease, and compared for differences in postoperative complications and survival. Using a multivariate logistic regression model CKD stage 3–4 was an independent factor for earlier noncancer-related death but not for overall or disease-free survival. In addition, patients with CKD stage 3–4 were noted to have more cardiovascular complications. The authors concluded that identification of CKD in routine preoperative assessment of colorectal cancer surgery may assist in more balanced decisionmaking, particularly in an increasingly older and comorbid patient group. Their study acknowledges several limitations in the discussion, and we would like to propose some other factors that may be of interest when considering the robustness and validity of their findings. It is readily apparent from the data that those with CKD stage 3– 4 are older, have greater cardiovascular and diabetic comorbidity and poorer tumour pathological characteristics including T stage and degree of differentiation. If CKD were not mentioned the reader might assume that the cause of early mortality is a combination of hypertension and/or diabetes. This assumption can have important consequences for the results, as CKD 3–4 may be a surrogate marker of the severity of any preoperative cardiovascular disease such as hypertension or of diabetic nephropathy, which may be the reason for greater cardiovascular complications following surgery rather than CKD per se. Furthermore can we then reliably extrapolate these results
to patients with advanced CKD, due for example to Fabry disease, glomerular nephritis, polycystic kidney disease or IgA nephropathy? While cardiovascular complications are more severe in CKD stage 3–4 than stage 0–2, would the findings have been the same if cardiovascular disease and/or diabetes had been compared in patients with and without CKD? Despite the adjusted multivariate model demonstrating that CKD is an independent factor for the outcome in the study, it does not distinguish between cause and effect. A prospective study looking at treatments to improve the glomerular filtration rate before surgery and its effects on the outcome is clearly warranted.
S. G. Farid, N. Shah, I. Wijetunga and D. Longbotham Department of Surgery, St James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK E-mail: [email protected] Received 7 June 2014; accepted 15 June 2014; Accepted Article online 12 August 2014
Reference 1 Currie A, Malietzis G, Askari A et al. The impact of chronic kidney disease on postoperative outcome following colorectal cancer surgery. Colorectal Dis 2014; 69: 879–85.
Improving timely detection and recording of colorectal peritoneal metastases doi:10.1111/codi.12794
Dear Sir, Dr Segelman and colleagues (Colorectal Dis 2014; 16: 359–367) have provided us with a practical tool that may predict and allow for the early detection and treatment of metachronous colorectal peritoneal metastases [1]. It is now widely accepted that surgical intervention in the form of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in appropriately selected patients with resectable peritoneal disease can improve outcome. Furthermore, intervention when disease volume is low is associated with a greater likelihood of complete resection and improved survival. This predictive tool may help us to identify patients with peritoneal metastases at an early stage when surgical intervention may be maximally beneficial. A focus on the early detection of recurrent disease also serves to raise our awareness further of
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 1019–1023
1019
