Late Renal Function Research Articles

Efficacy and late kidney effects of nephron-sparing surgery in the management of unilateral Wilms tumor: a systematic review and meta-analysis.

To evaluate the efficiency and long-term renal function of nephron sparing surgery (NSS) in unilateral WT patients compared with radical nephrectomy (RN). The review was performed following Cochrane Handbook guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched five databases (Pubmed, Embase, Scopus, Web of Science and Cochrane) for studies reporting the efficiency and late renal function of NSS and/or RN on February 10, 2023. Comparative studies were evaluated by Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) and RoB 2.0. Assessed outcomes included survival rate, relapse rate, eGFR, renal dysfunction and hypertension. 26 studies involving 10322 unilateral WT cases underwent RN and 657 unilateral WT cases underwent NSS were enrolled. Overall effect estimates demonstrated thatNSS significantly increased eGFR at follow-up (SMD, 0.38; 95% CI 0.05-0.72; p=0.025) compared to that at diagnosis, and RN did not significantly decrease eGFR at follow-up (SMD, -0.33; 95% CI -0.77-0.11; p=0.142) compared to that at diagnosis. Moreover, no significant difference was found in outcomes of survivability (OR, 1.38; 95% CI 0.82-2.32; p =0.226), recurrence (OR, 0.62; 95% CI 0.34-1.12; p = 0.114), eGFR at follow-up (SMD, 0.16; 95% CI -0.36-0.69; p = 0.538), renal dysfunction (OR, 0.36; 95% CI 0.07-1.73; p = 0.200) and hypertension (OR, 0.17; 95% CI 0.03-1.10; p = 0.063). Current evidence suggests that NSS is safe and effective for unilateral WT patients, because it causes better renal function and similar oncological outcomes compared with RN. Future efforts to conduct more high-quality studies and explore sources of heterogeneity is recommended.

Long-Term Propensity-Matched Comparison of Fenestrated Endovascular Aneurysm Repair and Open Surgical Repair of Complex Abdominal Aortic Aneurysms

Purpose: This study investigated the long-term outcomes of patients treated with fenestrated and branched endovascular aneurysm repair (F-BEVAR) or open surgical repair (OSR) for complex abdominal aortic aneurysms (c-AAAs). Complex abdominal aortic aneurysms are defined as aneurysms that involve the renal or mesenteric arteries and extend up to the level of the celiac axis or diaphragmatic hiatus but do not extend into the thoracic aorta. This study compares with a propensity-score matching the outcome of these procedures from 2 high-volume aortic centers. Materials and Methods: All patients with c-AAAs undergoing repair at 2 centers between January 2010 and June 2016 were included. The long-term imaging follow-up consisted in a yearly computed tomography angiography (CTA) in the F-BEVAR group. Yearly abdominal ultrasound examination and 5-year CTA were performed in the OSR group. The primary endpoints were long-term mortality, aneurysm-related mortality, and chronic renal decline (CRD), defined as estimated glomerular filtration rate reduction to <60 mL/min/1.73 m2 or >20%/de novo dependence on permanent dialysis in patients with normal or abnormal preoperative renal function, respectively. Secondary endpoints included aortic-related reinterventions, target vessel occlusion, proximal aorta degeneration, access-related complications, graft infection, and the composite endpoint of clinical failure during follow-up. Results: After 1:1 propensity matching, 102 consecutive patients who underwent F-BEVAR and OSR, respectively, were included. The median follow-up was 67 months. There was no significant difference in long-term overall mortality (40.2% vs 36.3%; p=0.40) and aneurysm-related mortality (6.8% vs 5.8%; p=0.30), in the F-BEVAR and OSR groups, respectively. During follow-up, late renal function decline occurred in 27 (27.8%) versus 46 patients (47.4%) in the F-BEVAR and OSR groups, respectively (p<0.01). During follow-up, 23 reinterventions (23.5%) were performed in the F-BEVAR group, and 5 (5.1%) in the OSR group (p<0.01). Conclusions: No differences in overall and aneurysm-related mortality were observed. Chronic renal decline was significantly higher after OSR, while the reintervention rate was higher in the F-BEVAR group. These long-term results reflect the outcomes of a complex procedure performed by a single experienced operator in 2 high-volume centers, and followed with a strict surveillance imaging follow-up. Clinical Impact Nowadays, F-BEVAR and OSR are considered two established techniques for the treatment of c-AAA. However, long-term comparative outcomes are not well studied, and concerns may rise in terms of durability of the repair, risk of reinterventions and late chronic renal decline. The present study showed, with a median follow-up > 5 years, no differences in overall and aneurysm-related mortality. Chronic renal decline was significantly higher after OSR, while the reintervention rate was higher in the endovascular group. To achieve the best possible long-term outcomes, both techniques should be performed in high volume aortic centres, tailored to the patient, and with an adequate surveillance imaging.

Kidney protection in thoracoabdominal aortic aneurysm surgery

Acute kidney injury (AKI) is a common complication of both open and endovascular repair of thoracoabdominal aortic aneurysms (TAAA). Its definition varies across difference studies, some standardized definitions (RIFLE, AKIN, KDIGO) have been proposed but still not uniformly employed in published papers. Acute kidney injury is multifactorial and is associated with increased in-hospital mortality, long-term mortality and late renal function decline. In addition, AKI is also associated with perioperative spinal cord ischemia. No specific pharmacological strategy has received a strong recommendation with high level of evidence as a protective measure. Fenoldopam, methylprednisolone or mannitol use to prevent AKI is commonly employed, but not supported by literature data. Avoiding nephrotoxic drugs and maintaining an adequate MAP, during and after the procedure plays a key role in preserving kidney function. During open TAAA surgery, renal arteries may be reimplanted using different techniques. The choice of the best option must be tailored to the patient, to reduce ischemic time and guarantee long-term patency. Current experience suggests that cold crystalloid solutions are the best substrates in preventing ischemia-reperfusion injury. Renal perfusion using Custodiol® (Dr Franz-Kohler Chemie GmbH; Bensheim, Germany) 4 °C, even if currently considered off-label, represents an encouraging organ protection tool. In endovascular TAAA repair, techniques such as fusion imaging, use of diluted contrast, and CO<inf>2</inf> subtraction angiography have the potential to reduce postoperative AKI. Visceral vessels patency is closely related to the anatomy. Therefore, accurate endograft design according to these characteristics is crucial for long-term preservation of renal function.

Correlation between preoperatively predicted and postoperatively observed renal function using an imaging-based approach: A retrospective cohort study.

The aim of the present study was to preoperatively predict renal function following partial nephrectomy (PN) using an imaging-based approach and to examine the correlation between preoperatively predicted and postoperatively observed renal function in the study cohort. A total of 128 consecutive patients who underwent PN between May 2015 and March 2018 and had available clinical data were included in this study. A hand-scripting method was used to estimate the defected volume (Vdef) from preoperative computerized tomography scans, whereas a cylindrical method was used to obtain preoperative renal volume (Vpre). The function index (FI) was proposed as a new term to estimate preserved parenchyma percentage following PN. The FI was defined as f=(Vpre-Vdef)/Vpre for the operated kidney and adjusted as FI=0.5 × (f + 1) for the bilateral kidneys. The estimated glomerular filtration rates (GFRs) before surgery, one day after surgery and ~12 months after surgery were calculated using the Modification of Diet in Renal Disease Study equation. The GFR rate after PN was predicted by multiplying the preoperative GFR by the FI. The predictive role of the FI was further tested using multiple linear regression and correlation analyses. The median FI in the present study was 94% for unilateral kidney surgery and adjusted to 97% for bilateral kidneys. Linear correlation analysis revealed that the predicted GFR significantly correlated with the observed immediate postoperative GFR (R2, 0.594) and observed late postoperative GFR (R2, 0.828). In multivariate regression analysis, preoperative GFR (P<0.01) and warm ischemic time (P<0.01) were identified as independent determinants of the immediate postoperative renal function, whereas only FI (P<0.01) and preoperative GFR (P<0.01) were identified as independent determinants of late renal function after PN. The preoperatively predicted renal function using an imaging-based approach had a significant positive correlation with the postoperatively observed renal function. The FI estimated from the preoperative diagnostic images in the present study was identified as an independent determinant of long-term renal function after PN.

Early and Long-term Efficacy of Fenestrated Endografting in the Treatment of Juxta-renal Aortic Aneurysms

Introduction - Juxta-renal aneurysms (j-AAAs) are increasingly repaired by endovascular means with fenestrated endografts (FEVAR) worldwide, however long-term data are presently lacking. Aim of our study was therefore to evaluate late outcome of FEVAR in j-AAAs Methods - Between 2008 and 2017, all consecutive patients undergoing endovascular repair for j-AAAs (neck length ≤5mm) by FEVAR (Cook-Zenith platform) were prospectively collected. Preoperative clinical and morphological features, together with procedural and postoperative data were analyzed. Early endpoints were: technical success (TS: patency of target visceral vessels; TVVs, absence of type I-III endoleak; iliac leg stenosis/occlusion and 24-hour survival), renal function worsening (reduction of baseline GFR ≥30%) and 30-day mortality. Late endpoints were: survival, freedom from re-intervention (FFR), TVV-patency, j-AAA shrinkage (> 5mm) and renal function worsening. Results - During the study period, overall 181 cases underwent FB-EVAR repair. Sixty-six patients with j-AAA (M: 94%; age: 72±6years; ASA 3/4: 79/21%) were enrolled. The mean j-AAA diameter was 58±6mm. Endograft with 1, 2, 3 and 4 fenestrations were planned in 2 (3%), 22 (33%), 27 (41%) and 15 (23%) cases, respectively. Overall, 236 TVVs were treated by fenestrations and scallops (3.6±1 TVV/patient). Technical success was achieved in 65 cases (99%). The only failure occurred for a type III endoleak requiring renal artery relining on postoperative day 32. No TVVs were lost. Cardio and pulmonary morbidities were 5% and 6%, respectively. There were no cases of acute splanchnic ischemia. Renal function worsening occurred in 7 cases (10%): 4 returned to baseline within 30-day; 1 required hemodialysis and died within 30-day (1.5%). This was the only case of 30-day mortality. The mean follow-up was 46±32 months. Aneurysm sac shrinkage or stability was observed in 42 (64%) and 22 (33%) cases, respectively. Two patients (3%) with persistent type II endoleak had sac enlargement and required re-interventions (sac embolization by trans-limb approach). Freedom from re-interventions at 1, 3 and 5 years was 97%, 93% and 88%, respectively. An asymptomatic celiac trunk occlusion occurred at 36-month in a case with asevere pre-operative stenosis - accommodated by a scallop. No late renal arteries occlusions or type I-III endoleaks occurred. Overall, renal function worsening was reported in 5 patients (8%) during follow-up (2 persisted from post-operative period and 3 with new onset). Survival at 1, 3 and 5 years was 92%, 86% and 67%, respectively, with no j-AAA related mortality. At the univariate analysis, COPD (p:.006), BMI >31 (p:.048), preoperative chronic renal failure (p:0.44) and late renal function worsening (p:.050) were risk factors for mortality. COPD was the only independent predictor for mortality at the multivariate analysis (p:.021; OR:5.3; 95%CI, 1.3-21.9) Conclusion - FEVAR for j-AAAs is safe and effective at early and long-term follow-up. According with the results of this series, FEVAR could be proposed as the first line treatment for j-AAAs in anatomically fit cases if performed in high volume centers. Long term survival is reduced in the presence of pre-operative COPD. The results of the present series should be taken in consideration when considering alternative open surgery technique in the treatment of J-AAAs

Impact Of Accessory Renal Artery Exclusion During Fenestrated Endovascular Repair For Juxtarenal Aortic Aneurysm

Introduction - The purpose of this study is to determine the clinical impact of accessory renal artery coverage on the renal function after fenestrated endovascular repair (f-EVAR) for juxtarenal aortic aneurysm. Methods - Between January 2005 and December 2016, 77 patients had f-EVAR for juxtarenal aneurysm with the Cook Zenith fenestrated endograft. Retrospectively, pre-operative CT was reviewed for the number and the diameter of accessory renal artery and post-operative CT was analyzed for accessory renal artery thrombosis and renal infarct. Patients with at least one renal accessory artery covered by the endograft were in group Acc and patients without renal accessory artery covered were in group NoAcc. Immediate postoperative renal insufficiency was compared between both groups. During follow-up, significant renal dysfunction was defined by a 25% or more deterioration of estimated glomerular filtration rate asses on two or more successive control. Results - Sixty-one patients (79%) were included in group NoAcc and sixteen patients (21%) were included in group Acc, 21 accessory renal arteries were covered, 8 had a diameter ≥ 3mm and 4 patients had 2 renal accessory arteries. The demographics of the patients were similar, the median pre-operative serum creatinine levels (group NoAcc vs group Acc) were 92 mmol/L (range 49-156 mmol/L) and 99 mmol/L (range 72-163 mmol/L) (p = .692), median aneurysm diameters were 54 mm (range 50-89 mm) and 55.5 mm (range 52 - 63 mm) (p=.138), respectively. Median quantity of contrast medium was 204 ml (range 67 – 540) and 230 ml (range 120 – 450) (p=.526). On post f-EVAR CT, 4 patients had an identified renal infarct, all of them were secondary to intentional coverage of an accessory renal artery, no immediate renal stent thrombosis was observed. New onset of postoperative renal insufficiency was detected in 8% versus 12% (p=.630), mortality was 2% vs 6% (p=.374), in NoAcc and Acc groups, respectively. At 3 years, patient survival was 89% vs 84% (p=.358), freedom from renal function deterioration was 78% vs 74% (p=.702). Conclusion - This retrospective analysis found no immediate postoperative renal failure or late renal function deterioration resulting from accessory renal arteries coverage during f-EVAR for Juxta renal aneurysms.

P1671Subclinical persistent hemolysis may affect late renal function deterioration after HeartMateII implantation

Abstract Background Late renal function dysfunction is an increasingly recognized complication in continuous flow left ventricular assist device (CF-LVAD) patients. Although hemolysis is prevalent in CF-LVAD patients and hemolysis may deteriorate renal function, the influence of persistent hemolysis on renal function in CF-LVAD patients remains to be investigated. Purpose To investigate the influence of persistent hemolysis on renal function in CF-LVAD patients, using lactate dehydrogenase (LDH) as a sensitive marker of hemolysis. Methods Excluding patients who died or underwent pump exchange for pump thrombosis, we retrospectively reviewed 65 consecutive adults who underwent HeartMateII implantation in our center from May 2011 to October 2017. Patient characteristics, chronotropic change of estimated glomerular filtration rate (eGFR) and LDH values weekly for 4 weeks and every 4 weeks between 4 and 48 weeks after implantation were collected. Then, calculating mean LDH during 48 weeks after implantation, study population was divided into low and high mean LDH groups at the median value of mean LDH. Results The median value of mean LDH was 304 U/l. Compared with low LDH patients, though high LDH patients were more likely female and had smaller body surface area, there were no significant difference in pre-operative eGFR between the groups (66.0±23.7 vs. 70.2±25.7 ml/min/1.73m2, p=0.495). After 40 weeks after implantation, high LDH patients had significantly lower eGFR than low LDH patients (71.0±23.7 vs. 87.1±31.4 ml/min/1.73m2, p=0.024). In multivariate linear regression analysis, mean LDH [parameter estimate: −0.10 (95% CI: −0.17 to −0.04), p=0.003] and post-operative pulse pressure [parameter estimate: 0.71 (95% CI: 0.05 to 1.37), p=0.036] were significantly associated with eGFR change during 48 weeks after HeartMateII implantation. Univariate and multivariate linear regression analysis for eGFR change Univariate parameter estimate 95% CI p value Multivariate parameter estimate 95% CI p value Bilirubin, mg/dl 9.97 3.82 to 16.13 0.002 6.55 −0.43 to 13.53 0.065 BNP, pg/ml 0.01 0.00 to 0.02 0.044 0.00 −0.01 to 0.01 0.528 Mean LDH during 4 to 48 weeks, U/l −0.11 −0.18 to −0.05 &lt;0.001 −0.10 −0.17 to −0.04 0.003 Pre-operative right atrial pressure, mmHg 1.43 0.35 to 2.51 0.010 −0.06 −1.52 to 1.40 0.935 Post-operative pulse pressure, mmHg 0.77 0.03 to 1.52 0.042 0.71 0.05 to 1.37 0.036 Conclusions High mean LDH and low pulse pressure were associated with a significant decrease in eGFR late after HeartMateII implantation. Subclinical persistent hemolysis may be associated with late renal function deterioration in CF-LVAD patients.

Suprarenal fixation is associated with worse midterm renal function after endovascular abdominal aortic aneurysm repair compared with infrarenal fixation

BackgroundSeveral reports have indicated that suprarenal (SR) fixation may impair renal function after endovascular abdominal aortic aneurysm repair (EVAR). However, most were short-term or at most, 1-year observational studies; therefore, the midterm effects on renal function remain unclear. This study aimed to identify predictors of midterm renal dysfunction after EVAR and compare renal outcomes in patients after EVAR with SR and infrarenal (IR) fixation. MethodsA total of 467 patients who underwent EVAR of nonruptured IR abdominal aortic aneurysm between 2007 and 2014 were reviewed in a prospectively collected database. Patients on hemodialysis at baseline were excluded. Among the remaining patients, those with 3-year laboratory testing were included in this study. Patients who developed acute kidney injury were excluded from the late renal function estimation. Predictors of 3-year renal function decline were estimated using logistic regression analysis. In addition, patients undergoing EVAR with IR (IR group) and SR fixation devices (SR group) were propensity matched by age, sex, baseline renal function, baseline aneurysm diameter, comorbidities, smoking habits, and regular use of medicines that may act on kidney function. Changes in renal function after surgery were compared between the IR group and the SR group. ResultsDuring the study period, 237 patients (102 IRs and 135 SRs) were followed up with laboratory testing 3 years after surgery. Logistic regression analysis revealed that the use of a SR fixation device was independently predictive of a more than 20% decrease in the estimated glomerular filtration rate at 3 years after EVAR (odds ratio, 2.06; 95% confidence interval, 1.18-3.58; P = .011). Eleven patients who developed acute kidney injury (1 IR and 10 SRs) were excluded from the subsequent analysis. After propensity score matching, 87 pairs were selected (mean age, 77.2 ± 6.3 years; 151 males [86.8%]). The mean follow-up duration was 5.5 ± 1.8 years. In the SR group, estimated glomerular filtration rate at 3 years after surgery decreased significantly more than that in the IR group (mean of 17.8% vs 11.6%, respectively; P = .034). ConclusionsThis study suggests that, compared with EVAR with IR endograft fixation, EVAR with SR endograft fixation is associated with worse outcomes for midterm renal function.

Severe Acute Kidney Injury after Cardiac Transplantation is a Marker of Poor Early Outcome and Impacts on Late Renal Function - A UK Cohort Study

Purpose Severe acute kidney injury (AKI) requiring haemofiltration is associated with worse mortality post-cardiac transplantation, but its long-term renal consequences are not known. This study analysed its impact on the mortality and long-term renal function in adult cardiac recipients in the UK. Methods Characteristics including age, gender, pre-op cardiac pathology, and diabetes mellitus (DM), survival status, peri-op renal function, and post-op haemofiltration of all adult recipients, who underwent cardiac transplantation between 1995 and 2017 in the UK, were retrieved from the UK Transplant Registry. Serum creatinine was collected immediately pre-op, 3-month post-op, and annually afterwards, and eGFR was calculated using the abbreviated MDRD equation. Binary logistic regression was used to identify risk factors for post-op haemofiltration requirement. Multivariable Cox regression was performed to identify risk factors associated with mortality and development of stage 4 or 5 chronic kidney disease (eGRF Results From 1995 to 2017, 3365 adult patients received cardiac transplantation across 6 centres in the UK. Among them, 876 (26.0%) patients developed post-op severe AKI requiring haemofiltration. The risk factors of post-op haemofiltration include congenital cardiac disease (p = 0.002, OR 1.90) and age (p = 0.003, OR 1.01). Both 1-year survival, 59.8% (95% CI: 56.6-63.2%), and 5-year survival, 50.7% (95% CI: 47.2-54.4%) of this group were strikingly lower than that of the non-haemofiltration group, 89.2% (95% CI: 88.0-90.5%), and 78.4% (95% CI: 76.7-80.1%). Age (p = 0.002, HR 1.01), insulin dependent DM (p =0.002, HR 1.45), and haemofiltration (p Conclusion This study confirmed that severe AKI requiring haemofiltration is associated with worse mortality, especially within the first year post-op. Moreover, as predicted in the studies in non-transplant patients, it has an adverse impact on the long-term deterioration of recipients’ renal function.

Contrast-induced nephropathy after peripheral vascular intervention: Long-term renal outcome and risk factors for progressive renal dysfunction

ObjectiveContrast-induced nephropathy (CIN) is a frequently used quality outcome marker after peripheral vascular interventions (PVIs). Whereas the factors associated with CIN development have been well documented, the long-term renal effects of CIN after PVI are unknown. This study was undertaken to investigate the long-term (1-year) renal consequences of CIN after PVI and to identify factors associated with renal function deterioration at 1-year follow-up. MethodsFrom 2008 to 2015, patients who had PVI at our institution (who were part of a statewide Vascular Interventions Collaborative) were queried for those who developed CIN. CIN was defined by the Collaborative as an increase in serum creatinine concentration of at least 0.5 mg/dL within 30 days after intervention. Preprocedural dialysis patients or patients without postprocedural creatinine values were excluded. Preprocedural, postprocedural, and 1-year serum creatinine values were abstracted and used to estimate glomerular filtration rate (GFR). ΔGFR was defined as preprocedural GFR minus 1-year GFR. Univariate and multivariate analyses for ΔGFR were performed to determine factors associated with renal deterioration at 1 year. ResultsFrom 2008 to 2015, there were 1323 PVIs performed; 881 patients met the inclusion criteria. Of these, 57 (6.5%) developed CIN; 47% were male, and 51% had baseline chronic kidney disease. CIN resolved by discharge in 30 patients (53%). Using multivariate linear regression, male sex (P = .027) and congestive heart failure (P = .048) were associated with 1-year GFR decline. Periprocedural variables related to 1-year GFR decline included percentage increase in 30-day postprocedural creatinine concentration (P = .025), whereas CIN resolution by discharge (mean, 13.1 days) was protective for renal function at 1 year (P = .02). A post hoc analysis was performed with 50 PVI patients (randomly selected) who did not develop CIN, comparing their late renal function with that of the CIN group stratified by the periprocedural 30-day variables. Patients with CIN resolution at discharge had similar 1-year renal outcomes to non-CIN patients, whereas the CIN-persistent (at discharge) patients had greater renal deterioration at 1 year compared with non-CIN patients (P = .016). ConclusionsMale sex and congestive heart failure are risk factors for further renal function decline in patients developing CIN after PVI. The magnitude and duration of increase in creatinine concentration (CIN persistence at discharge) correlated with late progressive renal dysfunction in CIN patients, suggesting that early-resolving CIN is relatively benign.

Experience of percutaneous nephrolithotomy with the creation of nephrostomy tract by plasma vaporization.

To share our 7-year experiences of a safe and effective method for tract creation in percutaneous nephrolithotomy (PCNL). A total of 143 patients had received this kind of method for renal stone disease at our institute from May 2010 to December 2016. Finally, 130 patients with complete data were included. All patients underwent a bipolar resectoscope mounted with a plasma vaporization (PV) button electrode for tract creation. Data analysis included procedure time, length of hospital stays, blood transfusion rate, any early and late complications, renal function, and stone-free rate. The mean age of patients was 56.5years (range 26-84 years). Noticeably, no blood transfusion was necessary in this series. Mean length of post-operative stay duration was 2.6 ± 1.1days. The average operating time was 46min. Stone-free rate was 93.3% in the non-staghorn calculi group. There was no significant difference in change in renal function after the operation (P = 0.884). All posto-perative complications were Clavien grade 1 including fever (16.9%) and urine leak (1.5%) etc. There was no major complication. Based on zero blood transfusion rate, no major complication, and shorter post-operative stay duration (2.6days), the PV technique is safe and effective for less blood loss in comparison with other techniques for creating the nephrostomy tract for PCNL.

A propensity-matched comparison of fenestrated endovascular aneurysm repair and open surgical repair of pararenal and paravisceral aortic aneurysms

ObjectiveThis study investigated the outcomes of a current series of patients treated with fenestrated and branched endovascular aneurysm repair (F-BEVAR) or open surgical repair (OSR) for pararenal abdominal aortic aneurysms (pr-AAAs), including juxtarenal, suprarenal, and type IV thoracoabdominal aneurysms. This study compares the outcomes of these procedures from two high-volume centers without the bias induced by a learning curve. MethodsAll patients with pr-AAAs undergoing repair at two centers between January 2010 and June 2016 were included in a prospective database. Patients undergoing F-BEVAR and OSR were propensity matched for age, sex, anatomic criteria (aortic clamp site), coronary artery disease, chronic obstructive pulmonary disease, diabetes, smoking, chronic kidney disease, aneurysm diameter, and previous aortic surgery. The primary end points were mortality and dialysis. Secondary end points included any myocardial ischemia, respiratory and early procedural complications, acute kidney injury (AKI) according to RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal failure), spinal cord ischemia, a composite of these complications, and postoperative intensive care unit length of stay. During follow-up, all-cause survival and freedom from reintervention were compared, as was the patency of stented vessels and renal and visceral bypasses. Late renal function deterioration was evaluated. ResultsIn this period, 157 F-BEVAR patients and 119 OSR patients were operated on. After 1:1 propensity matching, the study cohort consisted of 102 F-BEVARs and 102 OSRs. In the matched population, an average of 2.5 vessels were treated per patient. Univariate analysis demonstrated no significant difference in 30-day mortality (2.9% vs 2.0%; P = .68), dialysis (4.9% vs 3.9%; P = 1), cardiac ischemic complications (3.8% vs 5.9%; P = .52), pulmonary complications (5.9% vs 5.9%; P = 1), or any complications (28.4% vs 30.4%; P = .63) in the F-BEVAR and OSR groups, respectively. AKI was significantly lower in the F-BEVAR group than in the OSR group (19.6% vs 52%; P < .001), as was severe AKI (>50% decrease in glomerular filtration rate, 6.9% vs 16.7%; P = .03). There was no spinal cord ischemia. The median intensive care unit length of stay was 1 day in both groups (P = .33). During follow-up, we found occlusions of five stented vessels and three surgical bypasses. Late renal function deterioration was comparable between the two groups. According to Kaplan-Meier estimates, all-cause survival at 24, 48, and 72 months was 85.6%, 66.8%, and 55.8% after F-BEVAR and 90.5%, 82.9%, and 68.5% after OSR (P = .04). Rates of freedom from reintervention were 97.6% vs 97.5% at 24 months, 90.1% vs 93.4% at 48 months, and 63.9% vs 93.4% at 72 months in the F-BEVAR and OSR groups (P = .05), respectively. Thus, both all-cause survival and freedom from reintervention were lower in the F-BEVAR group. ConclusionsThis propensity score analysis in patients with pr-AAA undergoing F-BEVAR or OSR suggests no difference in terms of 30-day mortality, dialysis, or organ-specific postoperative complications, with the exception of AKI. Postoperative AKI was significantly higher after OSR, although most patients had recovered before discharge. Our data suggest similar outcomes after F-BEVAR or OSR for pr-AAA.

Role of Clinical and Surgical Factors for the Prediction of Immediate, Early and Late Functional Results, and its Relationship with Cardiovascular Outcome after Partial Nephrectomy: Results from the Prospective Multicenter RECORd 1 Project

We sought to determine the predictors of short-term and long-term renal function impairment after partial nephrectomy. Clinical data on 769 consecutive patients who underwent partial nephrectomy were prospectively recorded at a total of 19 urological Italian centers from 2009 to 2012 in the RECORd 1 (Italian Registry of Conservative Renal Surgery) Project. We extracted clinical data on 708 of these patients who were alive, free of recurrent disease and with a minimum 2-year functional followup. Of the patients 47.3% underwent open, 36.6% underwent laparoscopic and 16.1% underwent robot-assisted partial nephrectomy. The median baseline estimated glomerular filtration rate was 84.5 ml/minute/1.73 m2 (IQR 69.9-99.1). Immediate (day 3 postoperatively), early (month 1) and late (month 24) renal function impairment greater than 25% from baseline was identified in 25.3%, 21.6% and 14.8% of cases, respectively. Female gender and the baseline estimated glomerular filtration rate were independent predictors of immediate, early and late renal function impairment. Age at diagnosis was an independent predictor of immediate and late impairment. Uncontrolled diabetes was an independent predictor of late impairment only. Open and laparoscopic approaches, and pedicle clamping were independent predictors of immediate and early renal function impairment. Overall 58 of 529 patients (11%) experienced postoperative cardiovascular events. Body mass index and late renal function impairment were independent predictors of those events. Surgically modifiable factors were significantly associated with worse immediate and early functional outcomes after partial nephrectomy while clinically unmodifiable factors affected renal function during the entire followup. Late renal function impairment is an independent predictor of postoperative cardiovascular events.

Spherical cap surface model: A novel method for predicting renal function after partial nephrectomy.

To estimate the percent functional volume preservation from preoperative images using a novel method, the spherical cap surface model, and to investigate whether this model can preoperatively predict renal function after partial nephrectomy. A total of 233 patients with renal cell carcinoma who underwent open or laparoscopic partial nephrectomy between January 2011 and December 2013 were included in the present study. The spherical cap surface model was used to calculate the estimated percent functional volume preservation on preoperative computed tomography, and the estimated percent functional volume preservation was multiplied by the preoperative estimated glomerular filtration rate to predict the postoperative estimated glomerular filtration rate. The occurrence of acute kidney injury also served as an outcome. Univariate and multivariate linear regression, and receiver operating characteristic curve analysis were used to test the model. The estimated percent functional volume preservation calculated by the novel model was significantly associated with both nadir percent estimated glomerular filtration rate preservation and late percent estimated glomerular filtration rate preservation in the multivariate analysis (the P-values were 0.021 and 0.043, respectively). Receiver operating characteristic curve analysis for predicting acute kidney injury after partial nephrectomy showed that volume preservation (P<0.001) and warm ischemia time (P=0.040) were both significant. Regarding the ability to predict a significant decrease in late renal function after partial nephrectomy, only volume preservation (P=0.044) was significant. Preservation of functional volume is the primary determinant of functional outcomes after partial nephrectomy. The spherical cap surface model seems to represent a promising tool to predict nadir and late postoperative renal function in patients undergoing partial nephrectomy.

Ex-vivo Renal Artery Reconstruction with Kidney Autotransplantation for Renal Artery Branch Aneurysms: Late Results of 67 Procedures

s 393 of this study is to determine the true incidence and long term outcome of CIN in the optimised CKD population. Methods: Consecutive patients with stage III-V CKD, undergoing peripheral (group 1) or cardiac (group 2) angiography at a single centre regional Australian hospital between 2005 e2015 were included. Patients concurrently dialysing were excluded. All patients underwent pre procedural medical optimisation by a renal physician (intravenous hydration with normal saline, blood pressure control, withholding ACE Inhibitors, Metformin and Frusemide). Low-osmolality non-ionic contrast diluted to 1/3 strength (group 1) or 1/2 strength (group 2) was used. CIN was defined as creatinine rise of>25% from baseline within 72 hours. Primary outcomewas incidence of CIN. Secondary outcomes were mortality at 6 months, progression to dialysis and long term progression of CKD. Results: 537 patients with CKD stage III-V underwent angiography. 222 patients concurrently dialysing were excluded. Median ages (group 1 n 1⁄4 75, Group 2 n 1⁄4 76, P 1⁄4 0.25) were similar; diabetes was more prevalent in group 1 (70.5%) (group 2 1⁄4 48.4%) (P 1⁄4 0.001) and ischaemic heart disease more prevalent in group 2 (60.0%), (Group 1 1⁄4 44.3%) (P 1⁄4 0.02). Median volume of contrast used was significantly lower for group 1 (n 1⁄4 35 mls, range 2.5 e350 mls) compared to group 2 (n 1⁄4 75 mls, range 20e357) (P < 0.001). Combined incidence of CIN was 3.7%. Incidence of CIN did not differ between groups (group 1 1⁄4 4.1%, group 2 1⁄4 3.2%, P 1⁄4 0.74). No patients with CIN died within 6 months. Follow up ranged from 2e73 months. No patient with CIN progressed to higher CKD stage or dialysis. Conclusion: CIN in CKD population is multifactorial and was not related to volume of contrast used. Pre procedural optimisation of CKD patients and low osmolarity contrast agents may reduce incidence of CIN to a level comparable with the general population. CIN in CKD patients does not lead to death or long term disease progression. Ex-vivo Renal Artery Reconstruction with Kidney Autotransplantation for Renal Artery Branch Aneurysms: Late Results of 67 Procedures B. Chavent, A. Duprey, V. Meyer-Bisch, J.N. Albertini, J.P. Favre, X. Barral, J.B. Ricco University of St Etienne Medical School, France Introduction: The objective of this study was to evaluate the long-term outcome of renal revascularization by ex-vivo renal artery reconstruction and autotransplantation for Renal Artery Branch Aneurysms (RABA) in view of preventing aneurysm rupture. Methods: From 1991 to 2014, 67 ex-vivo renal artery reconstructions with kidney autotransplantation were performed in 58 adults (mean age, 41 years) and in 9 children to repair 87 RABAs. The main underlying disease was fibromuscular dysplasia. The mean diameter of the RABA was 23.4 mm (12e 45 millimetres). Fifty-seven patients were hypertensive and were given a mean of 1.7 antihypertensive drugs per day, 61 patients had normal renal function and no patient was on haemodialysis, 7 patients (10%) were operated after failure of an endovascular procedure. The mean number of renal artery branches repaired per patient was 3.5 and multiple aneurysms were treated in 15 patients (22.3%). The hypogastric artery was used in 41 patients, the saphenous vein in 18 patients, the superficial femoral artery in 5 patients and a combination of different materials in 3 patients. Outcomes consisted in primary patency rates, antihypertensive medication requirements, renal function and mortality. Late graft patency, renal size, and cortical thickness were analyzed by yearly renal duplex ultrasound examinations. Results: One in hospital death (1.5%) occurred in a patient having undergone complex emergent aortic and renal reconstruction. Other perioperative complications included 4 bypass occlusions and one reoperation for bleeding. During a mean follow up of 9 years, 4 patients (6%) were lost to follow up. No other bypass occlusion occurred, while two bypasses required a percutaneous angioplasty. Primary patency and primary assisted patency were respectively 90% and 92.5% at 9 years. Survival was 94% at 9 years. Among the 57 hypertensive patients, 20 (35%) were cured and 14 (25%) were improved at 9 years with a significant reduction of antihypertensive medications (p < .05). Late renal function was preserved as measured by no change in all but 2 patients in estimated glomerular filtration rate compared with pre-intervention values. In addition, there was no difference in treated kidney size on follow up compared with pre-operative measurements. Conclusion: Ex-vivo renal artery reconstruction for complex renal artery branch aneurysms suppress the risk of rupture, confers a benefit in blood pressure and preserves renal function. Predicting Post-operative Delirium after Vascular Surgical Procedures.

Renal Function Decline in Patients Receiving Sodium Picosulfate/Magnesium Citrate or 2L PEG+bisacodyl in Preparation for Colonoscopy: A Retrospective Analysis

Introduction: To identify risk factors for potential persistent or late renal function decline (RFD) among the 1201 patients who received a nonphosphate, dual-action, low-volume bowel preparation containing sodium picosulfate, magnesium oxide, and citric acid (P/MC, Prepopik’) or 2L polyethylene glycol solution and two 5-mg bisacodyl tablets (2L PEG+bis, HalfLytely®) in preparation for colonoscopy. Methods: A retrospective analysis of 2 phase 3, randomized multicenter studies that investigated split-dose (SEE CLEAR I) or day before (SEE CLEAR II) P/MC versus 2L PEG+bis was conducted to assess potential risk factors associated with RFD. Patients with severe renal impairment were not included in the original studies. Two clinically distinct patient groups with a potential for RFD were identified: persistent (Group 1) patients with ≥ 25% decrease in eGFR or ≥ 25% increase in serum creatinine compared with baseline at, either the day of colonoscopy, 24-48 hours post colonoscopy, or 28 days post colonoscopy, and at 7 days post-colonoscopy; Late (Group 2) patients with ≥ 25% decrease in eGFR or ≥ 25% increase in serum creatinine at 28 days post colonoscopy compared with baseline. A reference population was also defined as patients whose eGFR and serum creatinine were within ± 15% of baseline at all visits during their study participation. Statistical Methods: Group 1 & Group 2 were analyzed separately. All potential risk factors were assessed for associations with RFD in univariate analyses within each study and arm combination. Factors that suggested a univariate association with RFD were further assessed by multiple logistic regression analyses. Study and treatment effects as well as their interactions with each other and the potential risk factors were considered. Stepwise variable selection was used with a P value of < 0.1 as the selection criterion. Results: The logistic regression model did not identify any treatment or study effects, or an interaction with the potential risk factors. The risk factors for RFD identified for Group 1 were any comorbidity of interest and any concomitant medication of interest present at baseline including: sedation, anesthesia, NSAIDs, ACE inhibitors, ARBs, thiazide diuretics, and loop diuretics. The risk factors for RFD identified for Group 2 were any comorbidity of interest and any concomitant medication of interest added between day 7 and day 28. Conclusion: This analysis did not identify any significant difference in the risk of renal dysfunction between P/MC and 2L PEG+bis. Identified risk factors were aligned with prior medical history and medication use. Disclosure: Funded by Ferring Pharmaceuticals Inc, Parsippany, NJ. Editorial assistance by The JB Ashtin Group, Inc. Disclosure - G Bertiger has served as a consultant to Ferring Pharmaceuticals Inc. A Pavlov is a consultant to Ferring Pharmaceuticals Inc. R Joseph, R Willey, and S Johansson are employees of Ferring Pharmaceuticals Inc.

Outcomes after abdominal aortic aneurysm repair requiring a suprarenal cross-clamp

The objective of this study was to analyze the early and late outcomes of patients who require a suprarenal aortic cross-clamp during elective open repair of an abdominal aortic aneurysm (AAA). Patients from 1998 to 2012 who required a suprarenal aortic cross-clamp during elective open AAA repair were reviewed. Data abstracted included demographics and comorbidities; preoperative, perioperative, and late renal function; late interventions related to AAA repair; and late mortality. A decrease in renal function was defined as a >30% decline in estimated glomerular filtration rate (eGFR) compared with the preoperative value. Primary outcomes included renal function, intervention-free survival, and overall survival. During the study period, 211 patients underwent open elective or urgent AAA repair; 69 required a suprarenal cross-clamp. The mean age was 71 years, and 80% were men. The mean preoperative creatinine concentration was 1.2 mg/dL, and the mean preoperative eGFR was 66 mL/min/1.73 m2. Location of the aortic cross-clamp was suprarenal (37), supramesenteric (21), and supraceliac (11). Perioperatively, 21 patients (30%) experienced a significant decrease in eGFR; four patients required hemodialysis. Six patients had full recovery of renal function by discharge. Perioperative morbidity and mortality were 35% and 4%, respectively. At a mean follow-up of 3 years, seven patients had an eGFR significantly less than the preoperative value. Late interventions related to the AAA repair were required in eight patients. Indications included wound complication (3), anastomotic aneurysm (2), incisional hernia (1), anastomotic graft stenosis (1), and proximal aortic dilation (1). Overall 5-year intervention-free survival was 62% and overall survival 77%. Intervention-free survival was enhanced by antiplatelet use (P = .04), whereas overall survival was decreased by chronic obstructive pulmonary disease (P = .003) and perioperative pneumonia (P = .001). More than a quarter of patients requiring a suprarenal cross-clamp during open AAA repair experience renal dysfunction. Late graft-related complications are few, with preoperative and perioperative pulmonary function negatively affecting overall patient survival.

Ex vivo renal artery reconstruction for complex renal artery disease

The objective of this study was to evaluate long-term outcome of renal revascularization by exvivo renal artery reconstruction for complex renal artery disease. From 1987 to 2012, 23 patients (17 women; mean age, 45years) with complex renal artery lesions underwent open renal revascularization by exvivo technique. Underlying disease included fibromuscular dysplasia with aneurysm (11), atherosclerotic aneurysm (6), Takayasu arteritis (3), and other (3). Outcomes analyzed included primary, primary assisted, and secondary patency rates; antihypertensive medication requirements; renal function and preservation; and mortality. Late graft patency, renal size, and cortical thickness were analyzed by serial renal duplex ultrasound examinations. Twenty-four kidneys in 23 patients were revascularized by exvivo renal artery reconstructive techniques. Perioperative complications were limited to two patients requiring reoperation for bleeding. Renal function did not change, and there were no in-hospital deaths. During a mean follow-up of 44months, a single bypass graft occluded, requiring repeated bypass, which was performed with renal preservation. Primary, primary assisted, and secondary patency rates were 94% at 5 and 10years. Compared with preoperative values, systolic and diastolic blood pressure and the number of antihypertensive medications were reduced (P< .05) in the 18 patients with hypertension. Late renal function was preserved as measured by no change in both serum creatinine concentration and estimated glomerular filtration rate compared with preintervention values (P= .25 and P= .35, respectively). In addition, there was no difference in treated kidney size or renal cortical thickness on follow-up compared with preoperative measurements (P= .15 and P= .62, respectively). No patient required dialysis. There were three late deaths, none related to the renal procedure, providing 5- and 10-year survival of 85% and 68%, respectively. Exvivo renal artery reconstruction for complex renal artery disease confers a benefit in blood pressure while preserving renal mass and function. This technique should be considered a competitive alternative to other open surgical techniques for the management of complex renal artery disease.

Acute Kidney Injury Assessed by Cystatin C After Transcatheter Aortic Valve Implantation and Late Renal Dysfunction

The aim of the present study was to evaluate acute kidney injury (AKI) with cystatin C following transcatheter aortic valve implantation (TAVI) and to assess the impact of postoperative AKI on outcome and late renal function. A prospective study. Single, tertiary referral center. Sixty-eight consecutive patients with severe aortic stenosis and advanced comorbidity. Blood samples were collected on 4 occasions pre- and postoperatively to determine levels of s-creatinine and cystatin C. Additionally, a sample was collected at followup 12 months postoperatively for the determination of s-creatinine. The mean preoperative eGFR (s-creatinine) was 67±24 mL/min/1.73 m² compared to 45±21 mL/min/1.73 m² with eGFR (cystatin C) (p<0.001). Postoperative AKI was diagnosed in 25 patients (39%) with eGFR (cystatin C), compared to 21 patients (33%) with GFR (s-creatinine) and the RIFLE criteria. The 90-day mortality was 14.3% for the AKI+group and 2.3% for the AKI-group (p = 0.099). At 12 months followup, renal function remained impaired in patients with postoperative AKI and deteriorated in patients without. The risk of postoperative AKI is considerable following TAVI, with an increased risk of early mortality for AKI+patients. Cystatin C may be a valuable adjunct to the established biomarker s-creatinine for preoperative risk assessment and for early postoperative diagnosis of AKI. The acute postoperative renal impairment in patients with AKI does not fully recover in the long term. There is a progressive renal impairment in both groups postoperatively, the etiology probably being multifactorial.

A case-control study of intentional occlusion of accessory renal arteries during endovascular aortic aneurysm repair

The purpose of this study was to evaluate outcomes of patients treated by intentional coverage of accessory renal artery (ARA) during endovascular abdominal aneurysm repair (EVAR). The clinical data of 119 patients (110 male and nine female; mean age, 75years) from a cohort of 811 patients treated by EVAR from 1998 to 2009 was reviewed. Patients who had intentional coverage of at least one ARA (group A) were compared with two control groups, which included patients with no ARA (group B) and those who had ARA preserved during EVAR (group C). All three groups of patients were matched for age, gender, hypertension, and preoperative estimated glomerular filtration rate (eGFR). Paired pre- and postoperative computed tomography angiography was analyzed for the presence and volume of kidney infarction. End points were changes in eGFR, chronic kidney disease (CKD) stage, blood pressure measurements, presence and volume of kidney infarction, freedom from reintervention, and endoleak. There were 42 patients in group A, 42 in group B, and 35 in group C. Demographics, cardiovascular risk factors, and CKD classification were similar in all three groups. Among patients in group A, 44 ARAs were intentionally covered with ARAs originating from the proximal neck in 22 patients, the aneurysm sac in 20, and the iliac arteries in two. There was one (1%) early death in the entire study. Early morbidity was similar in all three groups, including four patients (9%) in group A, four (9%) in group B, and four (11%) in group C (P= .9). Six (5%) patients had >25% decrease in eGFR, including two who had ARA coverage. None of the patients required dialysis. After a mean follow-up of 37months, there were no differences in late renal function deterioration, changes in eGFR, CKD stage, or blood pressure measurements among the three groups. Three of the 18 patients (17%) with ARA >3mm arising from the aneurysm sac developed a type II endoleak requiring coil embolization. Kidney infarction was noted in 28 patients (67%) in group A. Freedom from reintervention at 2years was similar in groups A (64%), B (80%), and C (96%; P= .09). Intentional ARA occlusion during EVAR was not associated with changes in renal function or blood pressure measurements, even when performed in patients with more advanced renal dysfunction. Type II endoleak may result from persistent outflow into large (>3mm) ARAs that arise from the aneurysm sac.