Accelerated Recovery After Renal Cell Carcinoma and Partial Nephrectomy With Lifestyle Modifications

Abstract

Objective and subjective recovery times following a partial nephrectomy may exceed 1 year if patients adhere to the current Western lifestyle. This case demonstrates the rapid recovery of a 59-year-old female who underwent a robotic partial nephrectomy and utilized lifestyle modifications as an adjunct to the treatment of a Stage T1a clear cell renal cell carcinoma. All 6 pillars of lifestyle medicine are incorporated into this patient’s recovery plan, which successfully reduced her time to recovery after a partial nephrectomy. This case illustrates how modifications in diet, activity, sleep, stress management, social connectedness, and avoidance of risky substances may shorten recovery time after a partial nephrectomy and may serve as an example that providers can prescribe for patients recovering from other surgeries.

After either a radical or partial nephrectomy, the renal function deteriorates and may not return to baseline, even after 1 year.

The relative importance of preoperative renal function, preserved renal volume following partial nephrectomy, and duration of warm ischemia on renal function outcomes have been thoroughly investigated^1-5; however, there is a paucity of studies surrounding lifestyle modification and time to recovery post nephrectomy. It has become apparent that by minimizing warm ischemia time and the volume of resection, physicians can improve the quality of recovery post nephrectomy.^1-6 There may be other lifestyle factors to take into consideration, namely; diet, activity, sleep, stress, social connectedness, and avoidance of harmful substances. After either a radical or partial nephrectomy, the renal function deteriorates and may not return to baseline, even after 1 year.^7,8 According to the Brady Urology Institute at Johns-Hopkins: taking daily walks is strongly advised, climbing stairs should be taken slowly, driving should be avoided for at least 1 to 2 weeks, absolutely NO lifting (greater than 20 pounds) or exercising for 6 weeks, and expect to return to work in 4 weeks. There is a substantial cost to the quality of life in these patients for more than a month. Can we facilitate an accelerated recovery post nephrectomy through lifestyle modification? The question is answered and described herein, whether or not we can accelerate healing post-partial nephrectomy with lifestyle modifications.

Case

A 59-year-old female (PN), retired physical therapist with a history of hypothyroidism and prediabetes, presents to her family physician for atypical right upper quadrant abdominal pain with a slightly elevated alkaline phosphatase (Table 1) and underwent abdominal ultrasonography. She was taking 175 mg levothyroxine daily and 2000 IU of vitamin D daily. While examining the gallbladder, her astute physician noticed a nonspecific 2.5 cm right renal mass and subsequently referred her for a renal computed tomography (CT) scan. The CT showed a 3.5 cm right renal mass that was suspicious for malignancy and led to referral to a renal surgeon. PN and the surgeon decided that a robotic partial nephrectomy would have the best possible outcome and was performed 2 weeks after initial diagnosis of her Stage T1a clear cell renal cell carcinoma (CCRCC). PN was told that the recovery from this procedure would be long and arduous, possibly lasting a year or longer before she felt “normal” again. Leading up to and following the partial nephrectomy, PN engaged in numerous lifestyle modifications to optimize her recovery. This case can give medical providers a foundation whereupon they may build lifestyle modifications to potentiate their patients’ recoveries. PN kept very accurate notes throughout the entire process and is the author’s mother.

Table 1.

Laboratory Values.

Analyte	Baseline, January 25, 2019	Diagnosis, April 26, 2019	1 Month postoperative, June 21, 2019	6 Months postoperative, December 2, 2019	12 Months postoperative, November 2, 2020
Na	140 mmol/L	141 mmol/L	143 mmol/L	142 mmol/L	140 mmol/L
K	3.8 mmol/L	3.9 mmol/L	4.0 mmol/L	3.8 mmol/L	4.1 mmol/L
Cl	105 mmol/L	102 mmol/L	104 mmol/L	107 mmol/L	106 mmol/L
CO2	25 mmol/L	29.9 mmol/L	31.2 mmol/L	26 mmol/L	25 mmol/L
Ca	10.4 mg/dL	9.8 mg/dL	9.8 mg/dL	10.3 mg/dL	9.6 mg/dL
BUN	13 mg/dL	11 mg/dL	13 mg/dL	8 mg/dL	14 mg/dL
Creatinine	0.86 mg/dL	0.92 mg/dL	0.96 mg/dL	0.69 mg/dL	0.76 mg/dL
Glucose	a 79 mg/dL	86 mg/dL	95 mg/dL	80 mg/dL	92 mg/dL
HbA1c	5.2%			5.0%	5.0%
Iron saturation	b (H) 52%			32%	26%
eGFR	74 mL/min	66 mL/min	63 mL/min	95 mL/min	85 mL/min
TProt	7.3 g/dL	7.8 g/dL		7.0 mg/dL
Alb	4.9 g/dL	4.7 g/dL		4.8 g/dL	4.4 g/dL
TBIL	1.3 mg/dL	0.6 mg/dL		0.8 mg/dL
ALP	b (H) 146 IU/L	b (H) 166 IU/L		b (H) 148 IU/L
AST	36 IU/L	26 IU/L		27 IU/L
ALT	36 IU/L	38 IU/L		31 IU/L
TCHOL	191 mg/dL			182 mg/dL	176 mg/dL
HDL-C	53 mg/dL			53 mg/dL	51 mg/dL
LDL-C	b (H) 121 mg/dL			b (H) 109 mg/dL	b (H) 107 mg/dL
TRIG	85 mg/dL			100 mg/dL	92 mg/dL
TSH	1.95 uIU/mL			2.04 uIU/mL	1.21 uIU/mL

Abbreviations: BUN, blood urea nitrogen; eGFR, estimated glomerular filtration rate; TProt, total protein; Alb, albumin; TBIL, total bilirubin; ALP, alkaline phosphatase; AST, aspartate transaminase; ALT, alanine transaminase; TCHOL, total cholesterol; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TRIG, triglycerides; TSH, thyroid-stimulating hormone.

^aPatient stopped taking metformin after this appointment.

^bValue above the reference range for the population.

Diet

Having kept a healthy weight for most of her life, PN’s body mass index (BMI) was consistently between 28 and 30 for the 10 years preceding her CCRCC diagnosis with a hemoglobin A1c (HbA1c) in the prediabetic range. She was not able to reduce her weight or feel truly “healthy” for years. Eighteen months prior to the surgery, and before her diagnosis of CCRCC, she began eating a whole-food diet consisting of approximately 80% plants and 20% animal products to help with her weight loss. She has many food sensitivities including gluten, dairy, eggs, soy, corn, peanuts, tree nuts, artificial sweeteners, and chocolate. This was a fairly healthy lifestyle for one to have and be diagnosed with renal cell carcinoma, but she was determined to improve her outcome with lifestyle modifications as an adjunct to surgery and move each lifestyle attribute more closely toward the optimal side.

After the partial nephrectomy, she focused on maximizing the nourishment to her body in order to allow for greater defense against the cancer and to facilitate recovery rate. She tried to eliminate all non-whole-food chemicals that entered her body by minimizing supplements and eating no processed foods in an attempt to reduce the workload on the kidneys during recovery.

The shift to a whole-food plant-based diet consisted of a fairly stable daily diet of nutrient-dense foods with the daily recipes listed in Table 2. She supplemented her nutrient-rich diet with 5000 IU vitamin D₃ daily, 500 µg vitamin B₁₂ tablet every other week (which she recently increased to 2000 µg each week), and fortified nutritional yeast, 225 µg iodine daily for her hypothyroidism, digestive enzymes prior to each meal for postprandial gastrointestinal discomfort, and 1 probiotic capsule daily. Postoperative hydration was approximately 100 to 120 ounces of water per day.

Table 2.

Daily Recipes Used by PN to Potentiate Recovery.

Smoothies:
1 full Vitamix blender of smoothie and consumed over the course of 1 day
7-8 cups	Power greens (spinach, kale, baby chard)
1 tsp	Ginger (finely chopped)
1/2 tsp	Turmeric
1/4 tsp	Black pepper
1/4 cup	Mint leaves
1/2 lemon	Lemon
2 tsp	Cinnamon
1/2 cup	Whole flax seeds
1 cup	Blueberries (frozen)
3-4 cups	Water (depending on desired thickness)
Breakfast:
1 1/2 cups	Sprouted steel cut oats
1/2 cup	Pumpkin puree
1/4-1/2 cup	Chia seed pudding (3 cups of water + ½ cup hemp seeds, blended in Vitamix blender, then 9 tbsp of chia seeds added, plus pumpkin spice, cardamom, and orange peel)
Topped with blueberries and pumpkin seeds
Lunch:
Large salad with various greens (often romaine or butterhead with arugula)
A whole grain (brown rice, wild rice, or quinoa typically)
Legume: typically black beans, garbanzo beans, or lentils
Toppings typically included avocado, seeds, cauliflower, broccoli, Brussels sprouts, radishes, red onion, carrots, alfalfa and broccoli sprouts, cucumber, jicama, purple cabbage, red bell peppers, and clementines
Dressing was typically apple cider vinegar (or) mother of lime juice
Dinner:
Dinner was more variable, but typically included:
Homemade vegetable soup (or)
Plain baked potato and topped with a legume and steamed vegetables with a squeeze of lemon or lime and a few pumpkin seeds.

Movement/Activity

Preoperatively, she walked 6 days a week for 60 minutes per day with friends in their hilly neighborhood and attended 1 to 2 Pilates classes daily for 6 days a week. As a retired physical therapist, she designed her own rehabilitation program to maximize recovery. In the first postoperative day, she walked 280 minutes in 20- to 30-minute increments. She also did standing leg exercises thrice for 10 minutes each with single hand balance support on IV pole: squats, hip abduction, hip extension, hip flexion, hamstring curls, heel raises, and toe raises.

Typically movement after a partial nephrectomy is severely limited; the surgeon told PN that she would not feel good enough to exercise for possibly 6+ months. She took a proactive approach to fully understand what limitations she needed to work around.

I knew that I couldn’t be compliant with that, so I scheduled a separate appointment to fully understand what I was protecting and the time frames associated with the necessary healing. As a PT, but also as a regular exerciser who knows her body, I felt confident that I could progress my movement safely way earlier than 6 months. And after our discussion, he felt confident that I could, as well. He spent an entire hour answering questions and brainstorming a plan with me. (PN)

She was released home after only 1.5 days and she continued to walk outdoors at least twice per day. This high dosage of walking likely contributed significantly to her early discharge and rapid recovery. At 5½ weeks postoperative by 6/21, she was able to walk 60 minutes at a time while keeping a reasonable pace and talking. Beginning day 3 postoperative, she also continued her Pilates participation to regain her core strength with a few restrictions:

1. No Valsalva

2. Coordinated breathing with movement and exertion

3. Neutral trunk for first 6 weeks and never put her pelvis above her chest

4. No increase in pain

5. Frequent rest breaks

6. Kept resistance light

7. Focused on various planks for core work, avoided trunk movement with abdominal strengthening

Focus was placed on gentle arm and leg movements on a Pilates Reformer in her home while maintaining a neutral trunk position. Movements were progressed from recumbent to kneeling to standing as healing allowed. She continued single leg balance activities, lunges, heel raises, stairs. Initially, she started performing planks in an inclined position as her sutures were healing. At 3 weeks, she had returned to private lessons at the Pilates studio, and after 6 weeks the only limitation was to avoid any increase in pain. Her home activities began to include vacuuming and lifting most things after about 6 weeks. At 3 weeks, she began private lessons at the Pilates studio, while maintaining her precautions. Then at 6 weeks she returned to beginner-level classes at the studio, and progressed to more challenging classes as her strength and pain allowed.

She was able to perform activities of daily living independently from day 1, albeit slower and with guarded mobility. These included bathing/showering, dressing, eating, maintaining continence, and transferring/mobility. She prepared for her surgery by preparing all her food for the first postoperative week. After that, she was able to do all her own food prep, resumed lightly cleaning her house by week 2, and vacuuming at 6 weeks postoperative. By 3 months, she reports that she was “back to normal function.”

Sleep/Rest

Fatigue is generally a limiting factor after nephrectomy; for PN, it was a significant issue for 3 months. She slept more than 12 hours per day immediately postoperative, but gradually progressed to 10 hours per night with 1 to 2 naps during the day. By 6 weeks she was sleeping normally with 8 to 9 hours at night and no naps. She did have to sit and take rest breaks throughout the day and started water coloring to keep her mind busy during periods of rest.

Stress/Pain Management

PN has a very optimistic perspective on nearly everything in life, and this was no exception. There were no postoperative medications, other than Colace prescribed. She successfully managed pain with ice packs 20 to 30 minutes 6 to 8 times per day as needed for pain, which ceased by 6 weeks (June 21, 2020), after which she stopped icing daily and only iced on an as needed basis.

Social Connectedness

Six days per week, PN would walk with various friends and talk. These friends are predominately people with a positive outlook on life, just like PN, and helped create a rich social environment leading to rapid recovery. Additional benefits from her scheduled daily walks with friends and her Pilates classes were that they gave her day a predictable rhythm and structure with daily movement followed by rest and recovery time periods. It also gave her accountability and helped her consistently meet her goals of being active.

She would also spend one or more mornings per week with her grandchildren, which gave her a sense of meaning and purpose and “was the highlight of [her] week.” She also planned time to visit her other children and family members during this time.

Avoidance of Risky Substances

Her objective was to take in so many good nutrients for her body, that it did not leave any room for anything detrimental. She also did not drink or smoke prior to her diagnosis.

Discussion

Just as we once thought that immobilization and bed rest were proper treatments for postsurgical patients but now they are considered hazardous, perhaps the Western lifestyle should be considered deleterious to health for postsurgical patients. Surgeons may consider establishing lifestyle modification as the first-line treatment to speed and enhance recovery. This method of treatment may become similar to our current modus operandi of ambulating patients as soon as possible after surgery.

Her supplementation of vitamins could have been improved slightly. There has been a demonstration ⁹ that somewhere between 600 and 800 IU/day results in serum 25-(OH)VitD levels greater than an adequate concentration of 50 nmol in 97.5% of postmenopausal women. She was also supplementing with 500 µg of vitamin B₁₂ every other week. This was after she switched from eating mostly plants to eating exclusively plants, which possibly made her vitamin B₁₂ supplementation insufficient. One study ¹⁰ demonstrates that a dose of 50 µg/day is adequate to normalize methylmalonic acid and homocysteine levels. There currently is no agreement regarding the optimal definition of low vitamin B₁₂ status. ¹¹

All 6 pillars of lifestyle medicine likely potentiated PN’s recovery from CCRCC after partial nephrectomy. While this tumor was small, it is apparent that PN employed every available asset to parry the effects of this surgery. She had all the necessary whole foods to restrict the initiation and progression of cancer in her diet leading up to the surgery. ¹² She kept her activity level high throughout her recovery and was able to meet her weight loss goals with this lifestyle plan (Table 3). In addition to her weight loss, her total cholesterol decreased from 191 mg/dL to 176 mg/dL and low-density lipoprotein cholesterol from 121 mg/dL to 107 mg/dL.

Table 3.

Weight, BMI, and Blood Pressure.

	April 26, 2019	May 7, 2019	May 17, 2019	June 21, 2019	December 10, 2019	July 7, 2020	December 21, 2020
Weight	191	191	188	195	176	166	158
BMI	28.62	28.62	28.17	29.25	26.42	24.89	23.30
Systolic BP	112	116	111	113	148	115
Diastolic BP	69	79	68	76	87	69

Abbreviations: BMI, body mass index; BP, blood pressure.

PN returned to nonstrenuous activity immediately after the surgery as compared with other patients undergoing partial nephrectomies (9.9-19 days). ¹³ PN was able to return to her active lifestyle within 1 to 2 months. This allowed her life fulfillment and enjoyment of playing with her grandkids to rapidly return, further accelerating recovery. The time to physiologic recovery from partial nephrectomy is generally considered to be 6 to 12 weeks ¹⁴ to normal function, yet PN’s blood urea nitrogen and creatinine levels never deviated significantly.

PN demonstrated a high level of preparation to optimize the results of this surgery, also known as “prehabilitation,” which consists of various modalities designed to improve psychological, physiological, physical, or metabolic competencies of the patient prior to surgery. A study evaluating postsurgical recovery and preoperative physical activity in a cohort of breast cancer patients noted that there was an 85% greater chance for patients with high levels of physical activity to feel fully recovered after 3 weeks than patients with low levels of physical activity. ¹⁵ This acceleration of recovery is caused by activity, which is simple and inexpensive enough that all patients could take part, at least at some level. There is a paucity of evidence demonstrating the acceleration of recovery after a renal transplant, abdominopelvic surgery, and cancer surgery in general. ¹⁴ This is an opportunity for further investigation.

A brief review of just a few of the underlying biological mechanisms at play here; of note, there are more identified and yet-unidentified mechanisms that may contribute to PN’s recovery. Proteins, carbohydrates, arginine, glutamine, polyunsaturated fatty acids, vitamin A, vitamin C, vitamin E, magnesium, copper, zinc, and iron all play a significant role in wound healing. ¹⁵ Curcumin also seems to potentiate wound healing^16,17 and reduces general inflammatory processes. Physical activity improves blood flow ¹⁸ through vasodilation and may reduce the formation of thrombi. ¹⁹ Her frequent engagement with her friends and family gave her social connection. Social and emotional support can be protective for health, and social isolation has been identified as a risk factor for all-cause mortality. ²⁰

PN’s surgeon told her to have very low expectations for 9 months and that she would need much more sleep, will feel tired most of the time, and that she will not feel fully herself for a year or more. The subjective “feeling like myself” is a very important lifestyle factor to take into consideration. How many patients make beneficial lifestyle changes only to regress weeks or months later because they do not feel like themselves. A key element demonstrated in this case was that PN had the mindset that she was a healthy person and she engaged in a healthy lifestyle to reflect that. Patients who are unsuccessful at losing weight or dieting may be changing their activities as recommended, but those changes do not last because they may not change their self-identity along with it. PN shifted her viewpoint to that of a person who engages in healthy habits intentionally to best confer health. Having the vision of a healthy future helped drive PN to a successful recovery and allowed her to return to full health without having to give up so many months of relative docility and unnecessary waiting.

It is important to note that PN possessed a higher level of motivation and knowledge than most patients and these findings may not be applicable to the general population. Further research is indicated to identify optimal methods that will lead to lasting lifestyle changes to potentiate recovery from surgery. Clinicians may consider using motivational interviewing strategies to motivate their patients to follow this prescription.