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Additional supporting information may be found online in
the Supporting Information section at the end of the article:
Table S1. Univariate and multivariate analyses of predictors
of CSS in intermediate-risk patients with mRCC at the time
of ﬁrst-line TKI.
Table S2. Univariate and multivariate analyses of predictors
of OS in intermediate-risk patients with mRCC at the time of
Editorial Comment from Dr Teishima and Dr Matsubara to Prognostic impact of the
pretreatment aspartate transaminase/alanine transaminase ratio in patients treated
with ﬁrst-line systemic tyrosine kinase inhibitor therapy for metastatic renal cell
Kang et al. reported the prognostic impact of the aspartate
transaminase (AST)/alanine transaminase (ALT) ratio, refer-
red to as the De Ritis ratio, in metastatic renal cell carcinoma
(mRCC) patients treated with ﬁrst-line systemic tyrosine
Their study showed that patients with a
higher De Ritis ratio had worse cancer-speciﬁc survival and
overall survival than those with a lower ratio. In addition,
multivariate analysis showed that the ratio was an indepen-
dent factor for predicting both cancer-speciﬁc survival and
overall survival. Because the prognosis of patients with
mRCC has been dramatically changing through the induction
of many drugs including targeted agents and immunocheck-
point inhibitors, identifying markers predicting the effect of
agents or the prognosis is very important. The relative ratio
of AST to ALT is routinely measured in real clinical practice
and is thought to be promising for clinical application.
When patients with mRCC are classiﬁed on the basis of
Memorial Sloan Kettering Cancer Center or International
Metastatic Renal Cell Carcinoma Database Consortium risk
criteria, a high percentage of patients are categorized as an
intermediate risk. As a result, many patients with different
prognoses are included in an intermediate risk group. Previ-
ous studies have shown the reclassiﬁcation of the intermedi-
ate risk group through the use of a pretreated C-reactive
or neutrophil-to-lymphocyte ratio.
In addition to
these reports, their data showed that a higher pretreated De
Ritis ratio was an independent factor for predicting cancer-
speciﬁc survival and overall survival in an Memorial Sloan
Kettering Cancer Center intermediate risk group, indicating
that the ratio might be useful for optimizing the risk classiﬁ-
cation of patients with mRCC.
There are issues that should be further discussed. One of
them is the inﬂuence of metastasis on the De Ritis ratio. The
statuses of metastasis including the number of metastatic
organs or metastatic sites are prognostic factors in mRCC. In
particular, the negative impact of liver metastasis on the prog-
nosis of mRCC patients was previously shown.
AST and ALT are routinely measured during an examination
for both the diagnosis and follow up of liver dysfunction,
liver metastasis is able to have more of an inﬂuence on AST
© 2018 The Japanese Urological Association
De Ritis ratio in mRCC