Prognostic role of pretreatment serum albumin in renal cell carcinoma: a systematic review and meta-analysis

Figures & data

Figure 1 Flow diagram of the study selection process.

Table 1 Main characteristics of all studies included in the meta-analysis

Study	Country	Tumor type	Case number	Age (years)	Sex (M/F)	TNM stage (I/II/III/IV)	Fuhrman grade (I/II/III/IV)	Treatment	Follow-up (months)	Survival analysis	Cut-off value	Multivariate analysis	HR
Kim et al^Citation38 (2003)	USA	RCC	1,046	Mean 59	697/349	290/93/182/397	117/446/307/45	Surgery	Median 24.5	CSS	3.6	Yes	Report
Ramsey et al^Citation14 (2007)	UK	mRCC	119	56/63 (≤60/>60)	85/35	NR	NR	MT	Median 10	CSS	3.5	No	Report
Kim et al^Citation39 (2004)	USA	lRCC	250	Mean 62.5	43/207	NR	72/141/31/1	Surgery	Median 43	CSS	3.5	No	Report
Ramsey et al^Citation15 (2008)	UK	lRCC	83	40/43 (≤60/>60)	50/33	37/11/33/2	10/27/26/14	Surgery	Median 38	CSS/RFS	3.5	No	Report
Wang et al^Citation16 (2000)	People’s Republic of China	RCC	231	93/138 (≤60/>60)	181/50	158/73 (I–II/III–IV) (T stage)	NR	Surgery	Median 35.6	OS	3.5	No	Report
Kaffenberger et al^Citation17 (2012)	USA	lRCC	900	437/463 (≤60/>60)	581/319	474/100/291/34 (T stage)	102/428/230/112	Surgery	Median 28.7	OS/CSS	3.5	Yes	Report
Fox et al^Citation18 (2013)	Australia	mRCC	362	Median 62	268/94	NR	NR	MT	NR	OS	3.5	No	SC
Atkinson et al^Citation19 (2014)	USA	mRCC	185	Median 60	138/47	NR	NR	Targeted therapy	NR	OS/PFS	4.0	Yes	Report
Yap et al^Citation20 (2013)	Malaysia	RCC	151	Median 60.7	101/50	66/25/10/50	11/50/24/10	MT	Median 26	CSS	3.5	Yes	Report
Stenman et al^Citation21 (2014)	Sweden	mRCC	84	Median 67	57/27	NR	NR	Targeted therapy	NR	OS	3.0	Yes	Report
Furukawa et al^Citation22 (2015)	Japan	mCCRCC	209	Mean 66	161/48	71/138 (I–II/III–IV) (T stage)	NR	MT	Median 36.9	OS/PFS	3.5	Yes	Report
Corcoran et al^Citation23 (2015)	USA	mRCC	246	124/122 (≤60/>60)	176/70	174/72 (I–II/III–IV) (T stage)	40/200 (I–II/III–IV)	Surgery	Median 17	OS/CSS	3.5	Yes	Report
Sharma et al^Citation24 (2015)	USA	mRCC	93	Median 61	65/28	22/71 pT1a–pT2b/≥pT3c	16/77 (I–II/III–IV)	Surgery	Median 13	OS	3.5	Yes	Report
Chang et al^Citation25 (2015)	People’s Republic of China	CCRCC	441	Median 56	318/123	297/30/108/6	72/202/106/61	Surgery	Median 66	OS	4.0	No	SC
Sacre et al^Citation26 (2016)	Belgium	mCCRCC	108	Median 59	74/34	NR	24/78 (I–II/III–IV)	MT	Median 40	OS	3.5	No	Report
Hakimi et al^Citation27 (2013)	USA	CCRCC	2,119	Median 61	1,408/711	1,325/98/506/188	98/1,095/738/170	Surgery	Median 4 years	CSS	4.0	Yes	Report
Malik et al^Citation28 (2014)	USA	mRCC	70	Median 56.5	46/24	NR	NR	MT	Median 10	OS	3.5	Yes	Report

Abbreviations: CCRCC, clear cell renal cell carcinoma; CSS, cancer-specific survival; HR, hazard ratio; lRCC, localized renal cell carcinoma; mCCRCC, metastatic clear cell renal cell carcinoma; mRCC, metastatic renal cell carcinoma; TNM, tumor node metastasis; MT, multiple therapy; NR, not reported; OS, overall survival; PFS, progression-free survival; RCC, renal cell carcinoma; RFS, relapse-free survival; SC, survival curve.

Figure 2 Forest plots of studies evaluating hazard ratios of decreased serum albumin levels for all renal cell carcinomas RCC.

Notes: (A) A decreased serum albumin level was associated with a shorter overall survival in RCC. (B) A decreased serum albumin level was associated with shorter cancer-specific survival and shorter progression-free survival/relapse-free survival in RCC. Weights are from random effects analysis.
Abbreviations: CSS, cancer-specific survival; HR, hazard ratio; OS, overall survival; RCC, renal cell carcinoma.

Figure 3 Forest plots of studies evaluating hazard ratios of decreased serum albumin levels for different tumor types.

Notes: (A) All-stage group. (B) Metastatic group. (C) Localized group. (D) Clear cell renal cell carcinoma. Weights are from random effects analysis.
Abbreviations: CSS, cancer-specific survival; HR, hazard ratio; OS, overall survival.

Table 2 The pooled associations between pretreatment serum albumin and the prognosis of RCC patients

Variables	Outcome	Studies	Patients	HR (95% CI)	P-value	Model	Heterogeneity
							I^2 (%)	P-value
All	OS	11	2,929	2.46 (1.92, 3.13)	<0.001	Random	54.7	0.015*
	CSS	7	4,664	2.22 (1.87, 2.64)	<0.001	Fixed	39.6	0.128
	PFS/RFS	3	477	1.75 (1.28, 2.38)	<0.001	Fixed	39.4	0.192
Tumor type
RCC (all-stage)	OS	2	672	1.88 (0.39, 9.11)	0.432	Random	85.6	0.008*
	CSS	3	3,316	2.12 (1.24, 3.62)	0.006	Random	76.0	0.016*
RCC (localized)	OS	1	900	2.27 (1.45, 3.54)	–	–	–	–
	CSS	3	1,233	2.66 (1.58, 4.48)	<0.001	Fixed	27.5	0.252
RCC (metastatic)	OS	8	1,357	2.48 (1.89, 3.25)	<0.001	Random	52.1	0.041*
	CSS	2	365	2.21 (1.56, 3.14)	<0.001	Fixed	0.0	0.602
CCRCC	OS	3	758	3.85 (2.27, 6.53)	<0.001	Random	58.5	0.090
	CSS	1	2,119	2.71 (2.07, 3.54)	–	–	–	–
Analysis type
Univariate	OS	8	2,581	3.02 (2.33, 3.93)	<0.001	Random	63.7	0.007*
	CSS	7	1,787	3.71 (2.50, 5.51)	<0.001	Random	49.9	0.076
Multivariate	OS	6	1,749	2.06 (1.69, 2.52)	<0.001	Fixed	0.0	0.957
	CSS	5	4,462	2.12 (1.59, 2.84)	<0.001	Random	52.5	0.078
Cutoff value
=3.5 g/dL	OS	8	2,219	2.39 (1.77, 3.24)	<0.001	Random	58.7	0.018*
	CSS	6	1,746	2.38 (1.80, 3.15)	<0.001	Fixed	0.0	0.615
Others	OS	3	710	2.62 (1.56, 4.38)	<0.001	Random	60.8	0.078
	CSS	2	3,165	1.97 (1.03, 3.77)	0.039	Random	87.5	0.005*
HR obtaining method
Reported in text	OS	9	2,126	2.41 (1.75, 3.33)	<0.001	Random	62.8	0.006*
	CSS	8	4,914	2.24 (1.89, 2.66)	<0.001	Fixed	40.9	0.106
Data extrapolated	OS	2	803	2.95 (1.90, 4.57)	<0.001	Random	54.7	0.137
	CSS	0	0	–	–	–	–	–

Note:

* Indicates that the difference was statistically significant.

Abbreviations: CCRCC, clear cell renal cell carcinoma; CI, confidence intervals; CSS, cancer-specific survival; HR, hazard ratio; OS, overall survival; PFS, progression-free survival; RCC, renal cell carcinoma; RFS, relapse-free survival.

Figure 4 Funnel plots for the evaluation of potential publication bias.

Notes: (A) Overall survival for all renal cell carcinomas. (B) Cancer-specific survival for all renal cell carcinomas.
Abbreviation: HR, hazard ratio.

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