Late Renal Function Research Articles

Early and Late Outcomes Following Abdominal Aortic Aneurysm Repair Requiring a Suprarenal Cross-Clamp

METHODS: Patients from 1998-2011 who required a suprarenal aortic crossclamp during elective open AAA repair were reviewed. Data abstracted included demographics, 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 eGFR as compared to the preoperative value. Primary outcomes included renal function, intervention free survival and overall survival.

Association Between Warm Ischemia Time and Renal Parenchymal Atrophy After Partial Nephrectomy

Renal parenchymal volume decrease after partial nephrectomy is associated with late functional outcomes. We examined the relative effects of resection related and atrophy related volume change on late kidney function. Data were analyzed from a cohort of 187 patients who underwent open, laparoscopic or robotic partial nephrectomy between 2009 and 2011. Total change in kidney size after surgery was expressed as percent functional volume preservation measured using the cylindrical volume ratio method. Renal atrophy was expressed as parenchymal thickness preservation, and was assessed by measuring parenchymal thickness before and after partial nephrectomy in regions of the operated kidney distant from the site of resection. Standard statistical analyses were conducted to assess relationships among variables. Mean (± SD) percent functional volume preservation was 92% (± 8%), which correlated with a late percent glomerular filtration rate preservation of 91% (± 12%). Mean parenchymal thickness preservation for the cohort was 99% (± 4%). Minimal atrophy was observed in patients with warm ischemia time less than 40 minutes (parenchymal thickness preservation range 98% to 100%). Atrophy was more pronounced in patients with warm ischemia time greater than 40 minutes (parenchymal thickness preservation 96%). Multivariate regression analysis showed correlation of percent functional volume preservation with atrophy; correlation of warm ischemia time, diameter-axial-polar nephrometry score and atrophy with percent functional volume preservation; and correlation of Charlson score and diameter-axial-polar nephrometry score with percent decrease in glomerular filtration rate. In most patients with warm ischemia time less than 40 minutes the incidence of parenchymal atrophy was minimal, suggesting that the kidney volume decrease after partial nephrectomy was predominantly resection related. Kidney volume decrease after partial nephrectomy in patients with warm ischemia time greater than 40 minutes appeared to be due to a combination of resection related and atrophy related changes.

The Registry of the International Society for Heart and Lung Transplantation: Fifteenth Pediatric Heart Transplantation Report—2012

The Registry of the International Society for Heart and Lung Transplantation: Fifteenth Pediatric Heart Transplantation Report—2012

04 Safety and efficacy of basiliximab vs. anti-thymocyte globulin in living donor high risk renal transplant recipients

04 Safety and efficacy of basiliximab vs. anti-thymocyte globulin in living donor high risk renal transplant recipients

The lack of impact of peri-implantation or late gestation nutrient restriction on ovine fetal renal development and function.

Unbalanced nutrition during critical windows of development is implicated in determining the susceptibility to hypertension and cardiovascular disease in adult life, but the underlying mechanisms during fetal life have not been fully elucidated. We investigated the effects of moderate nutritional restriction during critical windows in gestation on late gestation fetal sheep growth, cardiovascular and renal renin-angiotensin system function. Ewes were fed 100% nutrient requirements (control), or 40-50% nutrient requirements during the peri-implantation period (1-31 days gestation (dGA), PI40 and PI50), or 50% nutrient requirements in late gestation (104-127 dGA). At 125 ± 2 dGA, fetal cardiovascular and renal function were measured at baseline, and during frusemide, angiotensin II (Ang II), phenylephrine and hypoxia challenges. Maternal undernutrition had no effect on fetal biometry, kidney weight, nephron number, basal cardiovascular function or cardiovascular and renal responses to frusemide. Fetal blood pressure response to Ang II was blunted in PI50 (P < 0.05), but not in PI40 groups. There was no difference between groups in the cardiovascular or endocrine response to hypoxia. The lack of effect of moderate undernutrition within key developmental windows of fetal kidney development on fetal renal structure and function suggests that renal mechanisms do not underlie our previous observations of cardiovascular dysfunction in adulthood following early-life undernutrition.

772 FACTORS PREDICTING EARLY AND LATE RENAL FUNCTION AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: We prospectively assessed the impact of multiple factors affecting early, intermediate and late renal function after LPN. METHODS: Between 2004–2009, sixty-eight patients with 2 functioning renal units undergoing LPN were prospectively analysed. MDRD and Cockcroft Gault-calculated glomerular filtration rates (GFR), MAG-3 renograms with GFR and differential function were obtained at 1) preoperatively 2) immediately post-op ( 3 days) 3) intermediate post-op (6–12wks) and late post-op (one year). The impact of patient demographics, tumour characteristics and surgical factors on functional renal outcomes were assessed. Correlation analysis was first performed using Spearman correlation to elucidate factors correlated with GFR decline. Subsequent multivariate analysis was performed at each of the postop periods. Paired t-test was used to compare baseline GFR and renograms to these outcomes at each of the postoperative time periods. RESULTS: Spearman correlation determined that age, weight, pre-operative GFR, piece size and warm ischemia time (WIT) were correlated with early decline in GFR. However, multivariate analysis showed that in the immediate time period, only tumor weight and WIT were predictive of decreased renal function (p 0.01). As well, in the late post-op period, only the degree of early/intermediate reduction in renal function was predictive of persistent impaired renal function (p 0.00001). Paired t-test analysis showed that there was significant decline in renal function in the immediate and intermediate time points (p 0.001); this decline did not persist at one year, indicating capacity for late renal recovery (p NS). However, paired t-test using nuclear renogram studies showed that there was persistent dysfunction of the affected kidney at one year postop (41.7% vs 49.4% preop; p 0.001). Taken together, this indicates that late renal recovery may occur as a result of compensation from the contralateral renal unit. CONCLUSIONS: This study confirms the negative impact of warm ishemic time upon early renal function post-LPN. Importantly, this is the first study to show that the degree of initial renal functional loss is a key determinant to renal recovery at one year. Additionally, the function of the affected kidney remains compromised at one year, and recovery of renal function is primarily by compensation from the contralateral kidney.

Histopathologic Evaluation of Pretransplantation Biopsy as a Factor Influencing Graft Function After Kidney Transplantation in 3-Year Observation

Many factors affect long-term results in kidney transplantation including histologic damage as a independent predictor, eg, chronic allograft dysfunction (CAD) in protocol biopsies and age-dependent lesions. Histopathologic findings correlate with the incidence of delayed graft function, eventual renal function, and allograft survival, allowing a rather precise prediction of graft outcomes. We analyzed 92 thick-needle preimplantation renal biopsies and 29 from grafts after explantation. They had been preserved in 4% formalin and immersed in paraffin. Evaluable specimens contained ≥10 glomeruli and ≥2 arterial cross-sections. We analyzed tubulitis, intensity of acute tubular necrosis (ATN), inflammatory infiltration, glomerulonephritis, arterial hyalinization, arteritis, fibrosis, tubular atrophy, arterial intimal fibrosis, increased mesangial matrix, and glomerulosclerosis percentage, although for comparative analysis not only optimal ones were taken into consideration. Over postoperative time, we analyzed patient condition, urine output, serum concentrations of creatinine, urea, uric acid, and ions as well as necessity for postoperative dialysis, ie, delayed graft function (DGF). During the 3-year observation we analyzed living recipients, graft loss, death with a functioning graft, incidence of dysfunction (CAD), and acute rejection episodes (ARE). We observed significant correlations between immediate graft function (IGF) and lack of ATN in the pretransplantation biopsy. The presence of ATN significantly correlated with DGF and primary graft non-function. There was no correlation between renal function and arterial hyalinization or fibrosis, inflammatory infiltration, and tubular atrophy. Over postoperative time we observed significant correlations between IGF and the lack of interstitial fibrosis as well as significantly lower levels of creatinine, urea, and potassium as well as greater urine output early after transplantation. IGF correlated with shorter time to reach a creatinine level of 2 mg/dL, lower concentrations of creatinine, urea, and potassium, as well as greater diuresis during the first 5 days. In addition, lower creatinine and urea concentrations after 1 month and of urea at 6 and 36 months were associated with IGF. Female recipients showed lower concentration of creatinine over 3 months, of urea during the 1st day, and of potassium at 1 month; however, thereafter the differences were not significant. Better function of the right kidney was observed. The presence of severe ATN (ATN III) correlated with lower creatinine concentrations at 6 months and urea after 3 years. The presence of hyalinization in biopsies correlated with higher concentrations of urea at 1 year and of borderline significance after 3 years; surprisingly, potassium concentrations were lower after 2 and 3 years. The presence of inflammatory infiltrates correlated with higher creatinine concentrations after 1 and 3 years; similar correlations, albeit of borderline significance, were observed in tubular atrophy. Interstitial fibrosis correlated with creatinine concentrations during 10 days after the operation and after 12 months, also with potassium concentrations 5 days after the operation. Borderline correlations were observed between donor age and creatinine concentration in the first day after the operation, after 6 months, and time to achieve a creatinine concentration of 2 mg/dL. We observed that biopsies with greater numbers of glomeruli correlated with better graft function, namely, lower creatinine concentrations after 5 days as well as at 1 and 6 months, as well as lower urea concentrations after 5 days and 6 months. We also observed differences in renal function depending on gender. The presence of acute tubular necrosis, arterial fibrosis and a lack of inflammatory infiltration in pretransplantation biopsy correlated with worse late renal function. Explantation biopsies showed signs of CAD in 66.4% and histologic features of ARE in 38.51%.

Surgical factors affecting return of renal function after partial nephrectomy

Nephron-sparing surgery is becoming the standard treatment for small renal tumors. In this study, we investigate the relationship between operative factors and recovery of renal function after partial nephrectomy. Records of 141 partial nephrectomy patients at the University of Alabama Medical Center at Birmingham between 1999 and 2008 were reviewed retrospectively. Renal function was assessed preoperatively, at 1day (early) and 6months (late) postoperatively by calculated creatinine clearance (CC). Anesthesia time, arterial clamp time, use of ice slush, tumor size, and change in hematocrit following surgery were assessed for their impact on change in early and late renal function after adjusting for patient age, gender, race, co-morbidities, preoperative renal function and operative approach. Descriptive statistics are presented for independent predictors and research outcome by time points. Multivariate regression model was used to identify independent predictors of renal function. Increasing anesthesia time, clamp time, and postoperative hematocrit were associated with decreased renal function (CC) at 1day postoperative. At 6months, tumor size and change in early postoperative hematocrit predicted a decline in CC. In multivariate analysis, decreased renal function at 6months was predicted by change in postoperative hematocrit level. Long hilar clamp times and anesthesia times adversely affect early postoperative renal function but not late renal function. Intraoperative bleeding adversely affected renal function at both early and late time points. Limiting intraoperative blood loss may be more important than clamp times or renal cooling in the recovery of renal function after partial nephrectomy.

Expanding the criteria of renal kidneys for transplantation: use of donors with acute renal failure

Increased numbers of patients waiting for renal transplantation have led to widening selection criteria for grafts. Thus, we have evaluated the outcome of transplanted kidneys procured in the presence of acute renal failure (ARF). Transplant patients (n = 52) with a kidney procured with ARF were studied. Clinical data from donors and recipients, serum creatinine (SCr), creatinine clearance [estimated glomerular filtration rate (eGFR)], cold ischaemia duration, time to urine flow recovery or renal function recovery, and the number of haemodialysis sessions, were collected retrospectively. Mean donor age was 45.7 +/- 12.7 years, and the mean SCr at the time of harvesting was 276.3 +/- 104.2 micromol/l. Recipients' mean age was 51.1 +/- 12.1 years. After transplantation, recovery of renal function was observed after 7.6 +/- 7.1 days, and required 1.9 +/- 3.0 haemodialysis sessions. SCr was 124.6 +/- 49.5 micromol/l, and eGFR was 56.2 +/- 19.8 ml/min at last follow-up. eGFR was significantly lower if the donor's death was due to stroke or cerebral haemorrhage (CH), or if the donors had previous cardiovascular disease (CVD) (P < 0.02). Patients with eGFR of <50 ml/min (n = 23) had donors who were older, and whose cause of death was more frequently related to CVD factors or to CH/stroke (P < 0.03). There were no significant differences between the two groups regarding age of recipient, gender of the donor or recipient, cold ischaemia time, occurrence of cardiac arrest, collapse or acute rejection. Linear regression analysis indicated that donor age and occurrence of acute rejection were independent factors associated with eGFR. ARF before organ procurement does not have a negative effect on subsequent renal function. However, old age, CVD risk factors or CH, and late renal function recovery after transplantation are correlated with subsequent lower renal function. Thus, renal grafts with ARF can be used for renal transplantations.

Early renal function post-liver transplantation is predictive of progressive chronic kidney disease

Objective. With improvements in long-term results after liver transplantation, chronic kidney disease (CKD) has become a highly relevant problem. The early measurement of the glomerular filtration rate (GFR) can identify those patients who are at risk of developing CKD years after liver transplantation. The aims of this study were to describe the prevalence of CKD 5 years after liver transplantation, to study the correlation between measured GFR early after transplantation and late renal function and to identify patients at risk of developing late CKD after liver transplantation. Material and methods. A total of 152 patients who were at least 5 years post-liver transplantation were studied. Measured GFR with Chromium EDTA or iohexol clearance was followed-up for 5 years (n=152) and 10 years (n=41). Results. The overall decrease in measured GFR was 36% after 5 years and 42% after 10 years. Eight patients (5%) required renal replacement therapy. GFR levels pretransplantation showed a poor correlation with later renal function (at 5 years). The GFR measured at 3 months and 1 year post-transplantation correlated well with measured GFR at 5 years post-transplantation. Multivariate analysis showed that measured GFR of less than 30 ml at 3 months post-transplantation was significantly associated with CKD at 5 years post-transplantation. Conclusions. GFR levels below 30 ml/min/1.73 m2 at 3 months post-liver transplantation are associated with the development of later CKD Stage 4–5 long after liver transplantation. The importance of this finding is the possibility of identifying at an early stage those individuals that may benefit from early implementation of calcineurin sparing or a withdrawal regimen with the goal of preserving long-term renal function.

Open Repair of Aortic Aneurysms Involving the Renal Vessels

This retrospective review examines the open surgical repair of intact juxtarenal (JRAAs) and suprarenal (SRAAs) aortic aneurysms to estimate effects on survival and renal function. Patients undergoing open repair of JRAA and SRAA were identified. Preoperative medical comorbidities and perioperative and late outcomes were recorded. Primary end points were survival (perioperative and long-term survival) and changes in renal function (acute tubular necrosis [ATN], acute dialysis, and late functional decline). Associations between outcomes and clinical variables were examined using univariate and multivariate techniques. Between December 1996 and September 2006, 678 patients underwent open repair of aortic aneurysms, including 150 aneurysms involving the renal vessels (134 JRAAs, 16 SRAAs). Perioperative mortality was 3% and long-term survival was 69% at 5 years. Fourteen percent of patients experienced ATN, and 7% required acute in-hospital dialysis. Late renal function remained unchanged or improved in 75%. These results demonstrate a perioperative mortality and renal complication rate in keeping with previous reports of open abdominal aortic aneurysm repairs involving the renal vessels. Future implementation of branch and fenestrated aortic endografts to treat similar aneurysms should approximate these results prior to widespread acceptance.

Histopathologic Evaluation of Pretransplant Biopsy as a Factor Influencing Graft Function After Kidney Transplantation: A 1-Year Observation

Introduction Many factors affect long-term results in kidney transplantation including histologic damage as a independent predictor, such as chronic allograft/nephropathy in protocol biopsies and age-dependent lesions. Histopathologic findings correlate with the incidence of delayed graft function, renal function, and allograft survival, allowing a rather precise prediction of graft outcome. Materials and Methods We analyzed 92 renal thick needle preimplantation and 29 postexplantation biopsies. Biopsies were preserved in 4% formalin and immersed in paraffin. Optimal biopsies contained at least 10 glomeruli and at least 2 cross-sections of arteries. We analyzed tubulitis, intensity of acute tubular necrosis, inflammatory infiltration, glomerulonephritis, arterial hyalinization, arteritis, fibrosis, tubular atrophy, arterial intimal fibrosis, increase of mesangial matrix, and percentage of glomerulosclerosis. During the postoperative course we analyzed patients condition, exigency of postoperative dialysis, urine output, as well as serum concentrations of creatinine, urea, uric acid, and ions. During a 1-year observation period, we analyzed living recipients, graft loss, death with a functioning graft, incidence of nephropathy (CAN), and acute rejection episodes (ARE). Results We observed a significant correlation between immediate graft function (IGF) and lack of ATN in the pre-0 biopsy. We observed no correlation between renal function and arterial hyalinization and fibrosis, inflammatory infiltration, tubular atrophy. In the postoperative period, we observed a significant correlation between IGF and lack of interstitial fibrosis with significantly lower levels of creatinine, urea, and potassium and higher urine output early after transplantation. IGF and better function of the right kidney was correlated with shorter time to reach a creatinine level of 2 mg%. In the postoperative periods, we also observed a difference between renal function depending on gender. The presence of acute tubular necrosis, arterial fibrosis, lack of inflammatory infiltration in the pre-0 biopsy correlated with worse late renal function. Among explantation biopsies 65.5% showed signs of CAN, and 37.93%, histologic marks of ARE.

Early Experience of a Living Donor Kidney Transplant Program

ObjectivesLaparoscopic nephrectomy has been shown to reduce the morbidity of live donor nephrectomy, but post-transplant kidney function and safety issues with the procedure are still of some concern. The review of our early experience could detect errors that should be avoided in the refining of the technique. MethodsOur first sixty consecutive laparoscopic donor nephrectomies were analyzed retrospectively. ResultsThere were conversions to open surgery (5%), all three in the first 18 cases. All donors were alive at 1 year with a glomerular filtration rate of 85±21ml/min (78% of the basal). Patient and graft survival at 1 year was 100% and 95%, respectively. Creatinine nadir was achieved on post-transplant day 3 (creatinine, 176±122μmol/l). Late renal function proved a continuous improvement until the 2-year follow-up (creatinine, 135±29μmol/l). Renal function recovery was better in both recipient and donor when the donor was ≤50 years old, compared with older patients. Transplant complications that required reintervention included one ureteral fistula, one ureteral stenosis and one case of low renal flow that was re-vascularised. ConclusionsTechnical surgical aspects such the use of Haemoloc® clips in the clipping of the artery, the hand-assisted extraction of the kidney, a refined surgical technique during the transplant and avoidance of prolonged warm and cold ischemia, taken together with an adequate intraoperative hemodynamic management of the donor aid in avoiding life-threatening complications and achieving a good post-transplant renal function recovery.

Influence of Cytomegalovirus Disease on Early and Late Renal Graft Function

The role of cytomegalovirus (CMV) disease to induce chronic nephropathy using new immunosuppressive regimens is debated. This study sought to assess the influence of CMV disease on early and late graft function in relation to immunosuppressive therapy. Among 456 renal recipients transplanted from 1997 to 2003, 95 were diagnosed with CMV disease on the basis of clinical symptoms and the presence of pp65 protein. The patients were divided into 2 groups according to their immunosuppressive regimen: group I included 43 patients treated with cyclosporine (CsA), azathioprine (AZA), and prednisone (P); group II, 52 patients treated with calcineurin inhibitor (CI), mycophenolate mofetil (MMF), and P. A control group of 90 CMV disease-free renal recipients were transplanted in 2001. CMV disease occurred in 20.8% of renal recipients: 14.8% from group I and 25.5% from group II. CMV disease was diagnosed in 73 patients (76.8%) before the third month after transplantation. An acute rejection episode (ARE) appeared in 42 patients, of whom 31 had CMV disease diagnosed within 1 month after ARE, while 5 before an ARE. In six patients ARE was not time related to CMV disease. The serum creatinine values at 6 months after transplantation were significantly higher among the CMV versus control groups: 1.69 and 1.76 vs 1.49 ( P < .05). In patients with ARE and CMV disease, the serum creatinine value was also higher at 6 and 12 months after transplantation compared with patients without an ARE ( P < .03). One- and 3-year graft survival rates were 95.1% and 83.7% in group I versus 93.4% and 86.5% in group II versus 95.4% and 90.2% in the control group. In conclusion, CMV disease showed a negative impact on early graft function independent of the immunosuppressive regimen, an effect that was emphasized by an ARE.

Laparoscopic Live Donor Nephrectomy has Equivalent Early and Late Renal Function Outcomes Compared With Open Donor Nephrectomy

Laparoscopic Live Donor Nephrectomy has Equivalent Early and Late Renal Function Outcomes Compared With Open Donor Nephrectomy

Laparoscopic Live Donor Nephrectomy has Equivalent Early and Late Renal Function Outcomes Compared With Open Donor Nephrectomy

Laparoscopic Live Donor Nephrectomy has Equivalent Early and Late Renal Function Outcomes Compared With Open Donor Nephrectomy

Improving the Prediction of Donor Kidney Quality: Deceased Donor Score and Resistive Indices

The deceased donor score (DDS), expanded criteria donor (ECD) definition, and resistive index (RI) were developed for pretransplant evaluation of donors. DDS and ECD are determined by a calculation of risk from donor variables, while RI is determined from flow characteristics of kidneys during machine preservation (MP). This study was designed to compare DDS, ECD status, and RI as predictors of outcome after deceased donor transplantation. We were also interested to see if DDS or ECD could identify kidneys most likely to benefit from MP. We retrospectively reviewed 48,952 deceased donor renal transplants reported to UNOS from 1997-2002. DDS (0-39 pts.), ECD status (+ or -), and preservation technique (MP vs. cold storage [CS]) were determined in all cases. RI during MP was studied in a single-center cohort of 425 transplants. DDS was superior to ECD status and RI in its correlation with early and late renal function after transplantation. DDS identified a subgroup of ECD- kidneys, those with DDS > or = 20 pts, that functioned significantly below expectation and similar to ECD+ kidneys. Benefits of MP, which include improved early graft function and a trend towards longer graft survival, were greatest in the group of kidneys with DDS > or = 20 pts. DDS was the best predictor of outcome after deceased donor renal transplantation and may be useful in identifying kidneys most likely to benefit from MP.

Laparoscopic live donor nephrectomy has equivalent early and late renal function outcomes compared with open donor nephrectomy

Objectives To assess the patterns of early functional recovery and long-term function in laparoscopic and open procured live donor nephrectomy (LDN) kidneys, highlighting the radionuclide scan as an additional tool for assessment, because of concerns regarding renal functional recovery after laparoscopic LDN. Methods We reviewed the donor and recipient records of 101 laparoscopic and 35 open LDNs performed between August 1997 and September 2001. Data were collected on demographic, immunologic, and intraoperative variables and ureteral/vascular complications. Delayed renal function recovery in recipients was evaluated by serum creatinine greater than 2.5 mg/dL on postoperative day 5, dialysis in first postoperative week, and two renographic criteria—the time to peak activity and the time to one-half peak activity on postoperative day 5. Long-term outcomes were evaluated by serum creatinine at 1, 3, 6, and 12 months and 2 and 3 years, creatinine clearance at 1 year, and patient and allograft survival. Results Donor and recipient age, sex, body mass index, and number of HLA mismatches did not differ between the two groups. The mean operating room time and blood loss were comparable. No differences were found in the early functional parameters (renography, creatinine at postoperative day 1 and 5, or dialysis in week 1) or long-term outcome (patient and graft survival, creatinine, and rejection at 1 year and patient and graft survival at 1, 2, and 3 years). Conclusions Early recovery of graft function, longer term renal function, and 3-year patient and allograft survival are similar for live donor kidneys obtained by either a laparoscopic or an open surgical technique.

Value of early creatinine clearance to predict late renal function in pediatric heart transplant patients

We previously assessed long-term renal function in pediatric heart transplant (Tx) recipients and showed no difference in nephrotoxicity between tacrolimus and cyclosporine. The aim of the present study was to determine early predictive factors for late renal dysfunction.

Preservation of renal function with surgical revascularization in patients with atherosclerotic renovascular disease

ObjectiveClinical and anatomic factors predictive of a favorable response to renal revascularization performed for renal function salvage remain poorly defined. To clarify decision making in such patients we reviewed a contemporary experience of surgical renal artery revascularization (RAR) performed primarily for preservation of renal function. MethodsBetween June 1990 and March 2001 (ensuring 1 year minimum follow-up), 96 patients with renal insufficiency (serum creatinine [Cr] concentration ≥1.5 mg/dL) and hypertension underwent RAR for preservation of renal function. Study end points included early and late renal function response, progression to dialysis dependence, and long-term survival. Variables potentially associated with these end points were assessed with univariate analysis, Cox regression analysis, and logistic regression analysis, and survival was assessed with the Kaplan-Meier method. ResultsPerioperative failure of RAR occurred in 3 patients (3%), with perioperative mortality in 4 patients (4.1%); thus 92 patients were available for long-term follow-up (mean, 39 months). Mean patient age was 70 ± 9 years with a mean baseline Cr of 2.6 mg/dL (range, 1.5-7.8 mg/dL). Operative management consisted of aortorenal bypass in 38% of patients, extraanatomic bypass in 38% of patients, and endarterectomy in 24% of patients; 32% of patients required combined aortic revascularization and RAR, and 27% underwent bilateral RAR. At hospital discharge renal function had improved (20% decrement in Cr) in 41 (43%) patients, including 7 patients who were removed from dialysis; remained unchanged in 40 (41%) patients; and declined (20% increase in Cr) in 15 (16%) patients. At last follow-up renal function was either improved or unchanged in 72% of patients. Predictors of a favorable response to RAR at last follow-up included stable Cr at hospital discharge (odds ratio [OR], 7.1; 95% confidence interval [CI], 2.5-21.8; P = .0004) and decreased Cr at hospital discharge (OR, 16; 95% CI, 1.6-307.8; P < .0001); bilateral renal artery repair (OR, 3.1; 95% CI, 0.9-10.6; P = .07) approached clinical significance. Predictors of worsened excretory function at last follow-up included decline of renal function at hospital discharge (OR, 28.9; 95% CI, 5.0-165.4; P = .0002), intervention to treat unilateral renal artery stenosis (OR, 3.8; 95% CI, 0.8-16.6; P = .05), and level of baseline Cr (OR, 3.0; 95% CI, 1.0-4.0; P = .04). Progression to dialysis occurred in 16 (17%) patients. Dialysis-free survival at 5 years was 50%, and overall actuarial survival at 5 years was 59%. Predictors of progression to dialysis during follow-up included treatment of complete renal artery occlusion (OR, 6.2; 95% CI, 1.3-29.5; P = .02), early failure of RAR (OR, 3.1; 95% CI, 0.7-14.2; P = .04) and baseline Cr (OR, 2.9; 95% CI, 1.3-6.1; P = .006). ConclusionLong-term clinical success in the preservation of renal function, noted in 70% of patients, can be predicted by the initial response to RAR and by anatomic factors, in particular, bilateral repair. While extreme (mean Cr ≥3.2 mg/dL) renal dysfunction generally is predictive of poor long-term outcome, a subset of patients will experience favorable results, even to the extent of rescue from dialysis. These results may facilitate clinical decision making in the application of RAR for renal function salvage.