CKD as a preoperative prognostic factor for overall survival and metastasis-free survival in patients undergoing radical nephroureterectomy

Upper urinary tract urothelial carcinoma (UTUC) is an aggressive malignancy treated primarily with radical nephroureterectomy (RNU), yet reliable preoperative prognostic indicators remain limited. Chronic kidney disease (CKD) is common in patients with UTUC and may influence both treatment options and oncological outcomes, but its prognostic value before surgery has not been fully clarified. We retrospectively analyzed 298 UTUC patients who underwent RNU between January 2014 and December 2023. To balance baseline characteristics, 1:1 propensity score matching (PSM) was performed. Cox proportional hazards models and Kaplan–Meier analyses were used to evaluate the association between preoperative CKD and overall survival (OS), intravesical recurrence-free survival (IVRFS), and metastasis-free survival (MFS). Subgroup analyses were conducted in patients with impaired renal function (eGFR < 90 mL/min/1.73 m² or CKD stage ≥ 2). Additional preoperative clinical-stage-adjusted models included clinical T and N stage. The median follow-up was 39 months (IQR, 18.2–69.0), and preoperative CKD was present in 133 patients (44.6%). After PSM, 164 patients were included in the matched cohort. In the primary matched-cohort analysis, CKD (HR = 2.4, 95% CI = 1.3–4.2), bladder cancer history (HR = 2.9, 95% CI = 1.2–6.7), and high lymphocyte–monocyte ratio (HR = 0.57, 95% CI = 0.33–0.98) were associated with OS. IVRFS was associated with age, bladder cancer history, and positive urine cytology. For MFS, CKD (HR = 2.1, 95% CI = 1.1–4.1) and bladder cancer history (HR = 4.3, 95% CI = 1.8–10.0) remained associated with adverse outcomes. After adjustment for clinical T and N stage, CKD remained associated with MFS and OS, but not IVRFS. Among patients with impaired renal function, eGFR < 50 mL/min/1.73 m² and CKD stage 3b or greater were associated with significantly shorter OS. Preoperative CKD was associated with worse OS and MFS in UTUC patients after RNU. Patients with eGFR < 45 mL/min/1.73 m² or < 50 mL/min/1.73 m² had significantly worse OS than others within the impaired renal function cohort. These findings support the clinical relevance of preoperative renal function assessment in UTUC.