Long-term Preservation Of Renal Function Research Articles

Outcomes of percutaneous transluminal renal angioplasty for pediatric renovascular hypertension: a 12-year retrospective single-center experience.

Renovascular disease underlies 5-10% of all childhood hypertension. We evaluated the long-term outcomes of percutaneous transluminal renal angioplasty (PTRA) for pediatric renovascular hypertension (RVH). Data from 37 children with RVH who underwent PTRA of 45 lesions at our center from January 2010 to January 2022 were retrospectively evaluated. Postoperative blood pressure (BP), glomerular filtration rate (GFR), affected kidney size, restenosis, and complications were analyzed. Mean age, weight, and height of patients at first PTRA was 11.51±4.57 (range, 3-17) years, 45.37±22.29 (range, 13.40-106.00) kg, and 1.46±0.26 (range, 0.92-1.85) m, respectively. Technical success was achieved in 33 of 37 (89.2%) patients and 40 of 45 (88.9%) lesions, without surgery-related complications. At a median of 7.5 (range, 3-14) months, restenosis occurred in 6 (16.7%) patients and 7 (16.3%) lesions (all ostial and 6 with a length >15 mm), yielding a clinical beneficial rate from first PTRA of 83.3%. At 18- and 20-month follow-up the mean kidney length (29 kidneys) increased from 8.89±1.55 to 9.79±1.51 cm (P<0.001) and mean GFR (34 kidneys) from 32.28±19.22 to 41.24±13.24 mL/min (P<0.001). In this retrospective analysis, PTRA for the treatment of pediatric RVH can achieve satisfactory results. Angioplasty was associated with improved BP control and long-term preservation of renal function, as reflected by an increase in affected kidney size and a higher GFR.

Renal outcomes of children born with posterior urethral valves at a tertiary center: A 15-year retrospective review.

Posterior urethral valves (PUVs) is a congenital condition in which an obstruction in the urethra prevents drainage of urine from the bladder in males, with up to 60% of children diagnosed developing chronic kidney disease (CKD). The primary aim of this study was to identify novel factors that may predict development of CKD and end-stage real disease (ESRD ) in children with PUVs to potentially address modifiable factors and delay progression. The secondary aim was to compare rates of catheterization and incontinence between our patients and other case series to provide information to parents about long-term bladder outcomes. A single-center, retrospective cohort study was performed of all children referred to our multidisciplinary clinic for PUV diagnosis between 2005 and 2019. Univariable associations of different variables with the composite outcome CKD or ESRD were evaluated. Thirty of 46 patients (65%) developed CKD, with the majority (40%) being stage 2 CKD (n=12). Seven of 30 patients (23%) developed ESRD requiring renal replacement therapy. Fourteen of 26 (30%) required clean intermittent catheterization (CIC) initiation, with a median CIC initiation age of 4.3 years. Creatinine nadir post-valve ablation, oligohydramnios, and initiation of CIC are significant predictors of CKD development. This review reiterates that children born with PUVs have a high morbidity rate, with a high proportion developing CKD. Using a multidisciplinary approach to PUV patient care allows for better family education, early intervention of bladder dysfunction, and possibly better long-term preservation of renal function.

Dietary Contributions to Metabolic Acidosis.

Eating a net acid-producing diet can produce an "acid stress" of severity proportional to the diet net acid load, as indexed by the steady-state renal net acid excretion rate. Depending on how much acid or base is ingested or produced from endogenous metabolic processes and how well our homeostatic mechanisms can buffer or eliminate the additional acids or bases, we can alter our systemic acid-base balance. With increasing age, the kidney's ability to excrete daily net acid loads declines (a condition similar to that of mild CKD), invoking increased utilization of potential base stores (eg, bone, skeletal muscle) on a daily basis to mitigate the acid accumulation, thereby contributing to development of osteoporosis, loss of muscle mass, and age-related renal insufficiency. Patients suffering from more advanced CKD often present with more severe acid stress or metabolic acidosis, as the kidney can no longer excrete the entire acid load. Alkaline diets based on fruits and vegetables may have a positive effect on long-term preservation of renal function while maintaining nutritional status. This chapter discusses the biochemistry of dietary precursors that affect acid or base production.

Incidence, demographic, biochemical, and clinicopathological profile of primary IgAN in a tertiary care center from Northern India

BackgroundPrimary IgA nephropathy (IgAN) has variable distribution and clinicopathological spectrum throughout the world. We report the incidence, demographic, and clinicopathological profile of primary IgAN from a tertiary care center in Northern India.MethodsThis is a single-center, prospective, observational study conducted at Sheri- Kashmir Institute of Medical Sciences, J&K, India, from January 2015 to December 2018. The study was approved by the hospital ethical committee.ResultsA total of 106 patients were included in this study, accounting for 19% (106/558) of all native kidney biopsies done during the period from January 2015 till December 2018. Males and females accounted for 60.4% (64/106) and 39.6% (42/106), respectively, with a ratio of 1.5:1. The mean age was 31.37±11.60 years. Edema and hypertension were the most common presenting symptoms and signs, seen in 69 (65.1%) and 72 (67.9%) patients, respectively. The baseline 24-h urine protein excretion was 2.32 ±1.34 g, Nephrotic range proteinuria (≥3.5g/day) was seen in 23/106 (21.7%). Average serum creatinine was 1.6±0.80 mg/dl and estimated glomerular filtration rate using CKD-EPI was <60 ml/min/1.73 m2 in 48.1% of patients (51/106). In patients with < 1 g proteinuria, 36.8% had E1, 78.9% had S1, 36.8% had T1, and 42.1% had T2 lesions.ConclusionsIgAN is common in North India and has a more severe histopathological presentation, characterized by extensive sclerosis and tubulointerstitial fibrosis. Renal dysfunction and nephrotic range proteinuria are common. Hypertension, low eGFR, and proteinuria correlate with the presence of segmental scarring, endocapillary hypercellularity, and IFTA. Screening of asymptomatic individuals might help in early diagnosis and long-term preservation of renal function.

Long-Term Preservation of Renal Function in Septic Shock Burn Patients Requiring Renal Replacement Therapy for Acute Kidney Injury.

Background. The real impact of septic shock-associated acute kidney injury (AKI) on the long-term renal outcome is still debated, and little is known about AKI-burn patients. In a cohort of burn survivors treated by continuous renal replacement therapy (CRRT) and sorbent technology (CPFA-CRRT), we investigated the long-term outcome of glomerular and tubular function. Methods. Out of 211 burn patients undergoing CRRT from 2001 to 2017, 45 survived, 40 completed the clinical follow-up (cumulative observation period 4067 months, median 84 months, IR 44-173), and 30 were alive on 31 December 2020. Besides creatinine and urine albumin, in the 19 patients treated with CPFA-CRRT, we determined the normalized GFR by 99mTc-DTPA (NRI-GFR) and studied glomerular and tubular urine protein markers. Results. At the follow-up endpoint, the median plasma creatinine and urine albumin were 0.99 (0.72–1.19) and 0.0 mg/dL (0.0–0.0), respectively. NRI-GFR was 103.0 mL/min (93.4–115). Four patients were diabetic, and 22/30 presented at least one risk factor for chronic disease (hypertension, dyslipidemia, and overweight). Proteinuria decreased over time, from 0.47 g/day (0.42–0.52) at 6 months to 0.134 g/day (0.09–0.17) at follow-up endpoint. Proteinuria positively correlated with the peak of plasma creatinine (r 0.6953, p 0.006) and the number of CRRT days (r 0.5650, p 0.035) during AKI course, and negatively with NRI–GFR (r −0.5545, p 0.049). In seven patients, urine protein profile showed a significant increase of glomerular marker albumin and glomerular/tubular index. Conclusions. Burn patients who experienced septic shock and AKI treated with CRRT had a long-term expectation of preserved renal function. However, these patients were more predisposed to microalbuminuria, diabetes, and the presence of risk factors for intercurrent comorbidities and chronic renal disease.

POS-830 NEFECON FOR THE TREATMENT OF IgA NEPHROPATHY IN PATIENTS AT RISK OF PROGRESSING TO END-STAGE RENAL DISEASE: THE NEFIGARD PHASE 3 TRIAL RESULTS

Peyer’s patches located within the gut-associated lymphoid tissue have been identified as a major source of poorly O-galactosylated immunoglobulin A (IgA)1, which triggers the formation of nephritogenic immune complexes in IgA nephropathy (IgAN). The therapeutic potential of targeting Peyer’s patches in patients with IgAN was demonstrated in the Phase 2 NEFIGAN trial, which assessed the safety and efficacy of a novel targeted-release formulation of budesonide (NEFECON), designed to deliver budesonide to the Peyer’s patches in the ileum. Patients treated for 9 months with NEFECON 16 mg/day demonstrated a significant (~30%) reduction in urine protein-to-creatinine ratio (UPCR) compared with placebo, and stabilization of estimated glomerular filtration rate (eGFR). Based on these data, the Phase 3 NefIgArd trial is a two-part design: Part A evaluates proteinuria reduction as a surrogate of the effect of NEFECON on long-term kidney function preservation. NefIgArd is a randomized, double-blind, placebo-controlled clinical trial recruiting a total of 360 patients across 155 nephrology clinics in 20 countries. Patients must be aged ≥18 years with biopsy-confirmed primary IgAN, proteinuria >1 g/24 h and eGFR 35–90 mL/min/1.73 m2 despite optimized renin–angiotensin system blockade. Patients are randomized on a 1:1 ratio to NEFECON 16 mg/day or placebo. The primary endpoint, based on the first 199 patients, is the percentage decrease in proteinuria (UPCR) after 9 months of treatment. The secondary objectives include the difference in kidney function between NEFECON-treated subjects and those on placebo, as measured using eGFR, and the urine albumin-to-creatinine ratio (UACR) at 9 months compared with baseline. Between September 2018 and October 2020, 657 subjects were screened. Of these, 306 patients were randomized and 199 with 9 months of follow-up were included in the efficacy analyses of Part A of the study. At 9 months, the geometric mean UPCR was reduced by 27% in the NEFECON group compared with the placebo group (p=0.0005). At 9 months, the NEFECON group provided a statistically significant 7% (3.87 mL/min/1.73m2) treatment benefit on eGFR (p=0.0029), compared with placebo. There was a similar overall incidence of adverse events in the two treatment groups. The NefIgArd study met its primary endpoint and demonstrated a favorable safety profile. These results are indicative of a clinically meaningful reduced risk of future progression to end-stage renal disease in patients with IgAN treated with NEFECON. This trial will continue in order to validate UPCR reduction as a surrogate of long-term renal function preservation.

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.

Role Of Robot-Assisted Partial Nephrectomy For Renal Cell Carcinomas In The Purpose Of Nephron Sparing.

IntroductionSurgery remains the standard treatment for localized renal cell carcinomas, and partial nephrectomy is considered before radical nephrectomy with the aim of preserving renal function. This study aimed to compare robot-assisted and open partial nephrectomy for the purpose of nephron sparing.Materials and methodsWe retrospectively enrolled consecutive patients who received partial nephrectomy at a single tertiary medical center from January 2008 to January 2015. Medical records and radiographic images were reviewed. We analyzed the patients’ general characteristics, underlying disease, complications, length of hospital stay, renal tumor complexity, surgery type, renal function, and specimen and tumor size. A comparison between open and robot-assisted nephrectomy groups was performed.ResultsA total of 136 patients were enrolled, with a male to female ratio of 2:3 and a mean age of 57.8 years. Of these, 71 and 65 patients received open and robot-assisted surgery, respectively. Compared with the open group, patients who underwent robot-assisted surgery were significantly younger (56.0 versus 60.1 years old), had a longer operative time (303 versus 224 min), and a lower kidney ischemic time (33.4 versus 46.9 min). Given similar tumor sizes, the tumor-to-excision ratio was significantly higher in the robot-assisted group (51.7% versus 39.8%), and the excisional volume loss (EVL) was smaller (12.7 versus 19.6 mL). Preoperative glomerular filtration rate and EVL were significant predictors of long-term renal function preservation in the multivariate analysis.ConclusionWhen performing partial nephrectomy, a robot-assisted procedure could increase the accuracy of excision without increasing the risk of positive surgical margin. Lower EVL could assist in better long-term postoperative renal function preservation.

Early Proteinuria Lowering by Angiotensin-Converting Enzyme Inhibition Predicts Renal Survival in Children with CKD.

Background Although pharmacotherapeutic proteinuria lowering was found to be nephroprotective in adults, the predictive value of early drug-induced proteinuria reduction for long-term renal survival in pediatric CKD is unknown. We analyzed data from the ESCAPE Trial for a potential association between initial antiproteinuric effect of standardized angiotensin-converting enzyme (ACE) inhibition and renal disease progression in children with CKD.Methods In total, 280 eligible children with CKD stages 2-4 (mean age 11.7 years old, median eGFR 46 ml/min per 1.73 m2, 71% congenital renal malformations) received a fixed dose of ramipril (6 mg/m2 per day) and were subsequently randomized to conventional or intensified BP control. We assessed initial proteinuria reduction from baseline to first measurement on ramipril (at 2.5±1.3 months). We used multivariable Cox modeling to estimate the association between initial proteinuria reduction and the risk of reaching a renal end point (50% eGFR decline or ESRD), which occurred in 80 patients during 5 years of observation.Results Ramipril therapy lowered proteinuria by a mean of 43.5% (95% confidence interval, 36.3% to 49.9%). Relative to proteinuria reduction <30%, 30%-60% and >60% reduction resulted in hazard ratios (95% confidence intervals) of 0.70 (0.40 to 1.22) and 0.42 (0.22 to 0.79), respectively. This association was independent of age, sex, CKD diagnosis, baseline eGFR, baseline proteinuria, initial BP, and concomitant BP reduction.Conclusions The early antiproteinuric effect of ACE inhibition is associated with long-term preservation of renal function in children with CKD. Proteinuria lowering should be considered an important target in the management of pediatric CKD.

EXPERIENCE WITH VALSARTAN/SACUBITRILO IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Objective: The main cause of admission in patients with heart failure (HF) is congestion. Treatment is complex, because of resistance to diuretics, and limitation to the use of potassium-sparing drugs. This situation is particularly frequent in patients with heart failure and chronic kidney disease (CKD). Therefore, the use of a drug that acts simultaneously on the renin angiotensin aldosterone system (RAAS) and on the Nerprisilina, can play an important role. Objectives: To evaluate the use of valsartan/sacubitrilo in patients with congestive heart failure and kidney disease 3B-4, analyzing its impact in the improvement of symptoms as overload and the effect on renal function. Analyze the safety profile of the drug Design and method: Prospective observational study (October 2016-October 2017): 7 patients with heart failure, a depressed ejection fraction and dyspnea functional grade II/IV onwards, to which had been added Valsartan/Sacubitrilo, previous suspension of ACE inhibitors or ARA II that came taking Results: The proportion F/M was 5/2. The mean age was 71 years. All patients are hypertensive, (85.6%) diabetic, 71.4% dyslipidemic. The 71 % with Cardiomyopathy. The 57.1% was being treated with combinations of diuretics, reducing this number to the 28.6%, after adding the new drug. 3 of the 7 patients (42.9%) stopped diuretics. There were no significant changes in the glomerular filtration rate, proteinuria and arterial blood pressure. 4 of the 7 patients improved the degree of dyspnea. Only 1 of these patients went to the emergency room with symptoms of heart failure once treated with the drug. None of the patients had adverse effects which would lead to the suspension of the drug. Conclusions: Valsartan/sacubitrilo in patients with CKD is useful to improve the functional class in patients with heart failure, allowing a lower use of diuretics and reducing emergency visits for symptoms in relation to the decompensation of heart failure. It is a reliable drug and help in the therapeutic management of these patients It will be necessary to assess the impact on the long-term preservation of renal function.

Surgical and Minimally Invasive Therapies for the Management of the Small Renal Mass.

This article aims to summarise recent developments in surgical and minimally invasive therapies in the management of small renal masses (SRMs). The incidence of the small renal mass is increasing. Standard management of the SRM is partial nephrectomy. More recently, use of ablative techniques to manage the SRM has been increasing and an exciting array of technical advances is currently being made in the field. Nephron-sparing surgery looks set to become more financially viable with the advent of newer robotic platforms and, potentially, even less invasive with the evaluation of single-port access. Real-time imaging promises to improve tumour definition, nephron preservation and vascular management intraoperatively. Advances in surgical and minimally invasive therapies for the management of the SRM have the potential to improve cancer clearance and long-term renal function preservation. Patients will experience safer, more reliable and less invasive treatments for their small renal tumours. We describe the current advances underlying these changes.

Effects of sodium-glucose co-transporter 2 (SGLT2) inhibition on renal function and albuminuria in patients with type 2 diabetes: a systematic review and meta-analysis.

AimTo evaluate the effects of sodium-glucose co-transporter 2 (SGLT2) inhibition on renal function and albuminuria in patients with type 2 diabetes.MethodsWe conducted systematic searches of PubMed, Embase and Cochrane Central Register of Controlled Trials up to June 2016 and included randomized controlled trials of SGLT2 inhibitors in adult type 2 diabetic patients reporting estimated glomerular filtration rate (eGFR) and/or urine albumin/creatinine ratio (ACR) changes. Data were synthesized using the random-effects model.ResultsForty-seven studies with 22,843 participants were included. SGLT2 inhibition was not associated with a significant change in eGFR in general (weighted mean difference (WMD), −0.33 ml/min per 1.73 m2, 95% CI [−0.90 to 0.23]) or in patients with chronic kidney disease (CKD) (WMD −0.78 ml/min per 1.73 m2, 95% CI [−2.52 to 0.97]). SGLT2 inhibition was associated with eGFR reduction in short-term trials (WMD −0.98 ml/min per 1.73 m2, 95% CI [−1.42 to −0.54]), and with eGFR preservation in long-term trials (WMD 2.01 ml/min per 1.73 m2, 95% CI [0.86 to 3.16]). Urine ACR reduction after SGLT2 inhibition was not statistically significant in type 2 diabetic patients in general (WMD −7.24 mg/g, 95% CI [−15.54 to 1.06]), but was significant in patients with CKD (WMD −107.35 mg/g, 95% CI [−192.53 to −22.18]).ConclusionsSGLT2 inhibition was not associated with significant changes in eGFR in patients with type 2 diabetes, likely resulting from a mixture of an initial reduction of eGFR and long-term renal function preservation. SGLT2 inhibition was associated with statistically significant albuminuria reduction in type 2 diabetic patients with CKD.

Long-Term Outcome of 102 Cases of Lupus Nephritis: A Single-Center Cohort Study in Japan

Background: The mortality rate is higher in SLE patients with lupus nephritis (LN) than in those without nephropathy. Objectives: The aim of this study was to identify the factors affecting the long-term renal outcome in 102 patients with LN. Methods: This was a retrospective cohort study. Logistic regression analysis was used in a model to determine how independent variables predicted the outcome. The survival analysis was based on the Kaplan-Meier curve with subjects censored for death. Results: The 15-year survival rate was 93.5%, and the renal function non-deterioration rate was 78.3%. No influence of individual types of immunosuppressant drugs used was found on the renal function deterioration rate. In this study, the results of analysis identified only daily urinary protein excretion level as having any significant effect on the risk of progression of LN to renal failure. Conclusions: These results suggest that remission induction therapy and maintenance therapy focused on long-term preservation of renal function need to be selected for LN patients with a high daily urinary protein value at the start of treatment and for LN patients who fail to show any reduction of the daily urinary protein excretion level to 0.5 g or less at one year after the biopsy.

Urothelial-based reconstructive surgery for upper- and mid-ureteral defects: Long-term results.

Ureteral strictures can result in obstructive nephropathy and renal function deterioration. Surgical management of ureteral defects, especially in the proximal- and mid-ureter, is particularly challenging. Our purpose was to analyze the long-term outcomes of urothelial-based reconstructive surgery for upper- and mid-ureteral defects. We conducted a retrospective analysis of a single tertiary centre's database, including 149 patients treated for ureteral defects between 2001 and 2011. Thirty-one patients (21%) underwent complex urothelial-based surgical repairs for upper- and mid-ureter defects. Patients' median age was 61 years. The mean length of the ureteral strictures was 2.5 cm, located in upper-, mid-ureter, or in between in 19 (61%), 10 (32%), and two (6%) patients, respectively. All patients were treated with a primary urothelial-based repair. Median followup time was 26 months. The primary outcome of the study was the long-term preservation of renal function and lack of clinical obstruction. The secondary endpoint of the study was the assessment of the intra- and postoperative complication rates. Most of the lesions were benign (22, 71%), while nine strictures (29%) were malignant. Seven patients (23%) suffered from postoperative complications, five of which were infectious. The median pre- and postoperative calculated glomerular filtration rates were 66 ml/min/1.72m2 and 64ml/min/1.72m2, respectively. Success rate was 84%, defined as lack of need for re-operation or kidney drainage at the last followup. Upper- and mid-ureteral defects present a complex pathology necessitating experienced reconstructive surgical skills. Our data suggest good long-term results for primary urothelial-based reconstructions for these pathologies.

Con: Cyclophosphamide for the treatment of lupus nephritis.

Kidney involvement is a major determinant for morbidity and mortality in patients with systemic lupus erythematosus. The treatment target of lupus renal disease is to induce and maintain remission and to minimize disease or treatment-related comorbidities. Cyclophosphamide (CYC), in conjunction with glucocorticoids, has conventionally been used for the initial treatment of lupus nephritis. However, the major concerns of CYC are its toxicities, such as infertility, urotoxicity and oncogenicity, which are particularly relevant in women of childbearing age. As a result, maintenance therapy of lupus nephritis with an extended course of CYC pulses has largely been replaced by other immunosuppressive agents such as mycophenolate mofetil (MMF) and azathioprine. Recent randomized controlled trials have demonstrated non-inferiority of MMF to pulse CYC as induction therapy of lupus nephritis. Although MMF as induction-maintenance therapy has been increasingly used in lupus nephritis, its efficacy in the long-term preservation of renal function remains to be elucidated. MMF is not necessarily less toxic than CYC. Meta-analyses of clinical trials show similar incidence of infective complications and gastrointestinal adverse events in both MMF- and CYC-based regimens. However, considering the reduction in gonadal toxicity and the risk of oncogenicity, MMF may be used as first-line therapy of lupus nephritis. Tacrolimus (TAC) has recently been shown to be equivalent to either MMF or CYC for inducing remission of lupus nephritis and may be considered as another non-CYC alternative. Combined low-dose MMF and TAC appears to be more effective than CYC pulses in Chinese patients with lupus nephritis and has the potential to replace the more toxic CYC regimens in high-risk patients. Currently, CYC still plays an important role in the management of lupus nephritis patients with impaired or rapidly deteriorating renal function, crescentic glomerulonephritis or as salvage therapy for recalcitrant disease.

Open partial nephrectomy: ancient art or currently available technique?

Renal cell carcinoma (RCC) accounts for 3 % of adult solid tumors, with the highest incidence between 50 and 70 years of age. Nephron-sparing surgery was initially reserved to patients with small renal masses detected in anatomically or functionally solitary kidney or in the presence of multiple bilateral tumors or hereditary forms of RCC, which posed a high risk of developing a tumor in the contralateral kidney. Nowadays, partial nephrectomy (PN) has grown up to an established approach for the treatment of small renal masses. In patients with T1a-staged RCCs, PN has proven to be associated with better survival, long-term renal function preservation with lower dialysis need or renal transplantation. Currently, most of the kidney masses are incidentally detected, up to 40 %, with smaller size due to the widespread use of imaging modalities such as ultrasound, computed tomography and magnetic resonance. Here we review the role of open PN in the management of small renal masses particularly focusing on indications, oncological outcomes and comparison with laparoscopic and robotic PN. Recent studies demonstrate that PN confers better survival, oncologic equivalence and lower risk of severe chronic kidney disease compared to radical nephrectomy becoming then the gold-standard surgical technique, even if increasingly challenged by laparoscopic and/or robot-assisted partial nephrectomy which in the hands of experts seems to achieve comparable outcome results albeit with slightly higher complication rate.

FRI0376 Inclusion of Urine Sediment in the Response Criteria of A Lupus Nephritis TRIAL Undermines the Prognostic Value of Proteinuria Improvement as Best Predictor of Longterm Preservation of Renal Function: Data from the Euro-Lupus Nephritis Trial

BackgroundThere is controversy about what outcome measure in a lupus nephritis (LN) trial can be relied upon to predict longterm preservation of renal function.ObjectivesThis analysis was undertaken to determine which...

Laparoscopic and open partial nephrectomy: a UK centre's experience

Introduction Laparoscopy allows minimally invasive approaches for procedures traditionally performed openly, with associated lower morbidity. Nephron-sparing surgery (NSS) is mostly regarded as an open procedure because laparoscopic partial nephrectomy (LPN) is technically challenging. We evaluated our centre's experience with LPN and open partial nephrectomy (OPN). Methods All patients over five years (2005–2010) undergoing NSS were identified retrospectively from our operating room management information system. Case notes, diagnostic and post-operative surveillance imaging were reviewed. Post-operative morbidity, histopathology and serum full blood count and urea and electrolyte reports were recorded. Results A total of 97 OPNs and 23 LPNs were performed. Median length of stay was six days for OPNs and three days for LPNs (p= 0.005). Mean drop in haemoglobin (Hb) was 2.6 g/dl for both OPNs and LPNs. No significant difference in transfusion rates was observed. Median warm ischaemia time (WIT) for OPNs was 14 minutes and 32 minutes for LPNs (p &lt; 0.0001). No significant difference was seen in changes from baseline serum creatinine when comparing OPNs with LPNs at day 1 (p = 0.7572) and at 12 months (p = 0.7406) post-operatively. Surgical margins were positive in 20 (21.5%) OPNs and negative in all LPNs (p = 0.038). One patient developed local recurrence following OPN (clear margins) and two patients developed distant metastases. Conclusions Benefits of LPN include shorter hospital stay and satisfactory long-term preservation of renal function, despite longer WITs. This demonstrates the benefits of LPNs in patients with single exophytic renal tumours performed by highly experienced, regionally selected laparoscopists.

Off-Clamp Versus Complete Hilar Control Partial Nephrectomy for Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

To evaluate the safety, efficacy, and potential advantages of off-clamp partial nephrectomy (OFF-PN) compared with on-clamp partial nephrectomy (ON-PN). Relevant studies comparing the safety and efficacy of OFF-PN to ON-PN were identified through a literature search using MEDLINE, EMBASE, and the Cochrane Library. The outcome measures included baseline characteristics, primary outcomes, and secondary outcomes. Ten retrospective studies (728 cases and 1267 controls) were included. No significant differences between the two groups were detected in any of the baseline variables (age: p=0.19; sex: p=0.49; BMI: p=0.29; tumor size: p=0.44, pre-eGFR: p=0.78) except for tumor location (p<0.001). The OFF-PN group had a higher blood transfusion rate (odds ratio [OR] 1.54, 95% confidence interval [CI] 10.7-2.21, p=0.02), a lower postoperative complication rate (OR 0.61, 95% CI 0.44-0.83, p=0.002), and a lower positive margin rate (OR 0.49, 95% CI 0.26-0.90, p=0.02) than ON-PN. OFF-PN offered a better preservation of renal function than ON-PN (p=0.005). No significant differences were detected between the two groups in other outcomes of interest. In sensitivity analysis, there was no change in the significance of any of the outcomes except for postoperative complication rate (OR 0.91, 95% CI 0.53-1.5, p=0.73) and positive margin rate (OR 0.55, 95% CI 0.25-1.23, p=0.15). This meta-analysis suggests that with appropriate patient selection, OFF-PN offer comparable perioperative safety, equivalent oncologic outcomes, and superior long-term renal function preservation when compared with ON-PN for renal cell carcinoma. Given the inherent limitations of the included studies, future well-designed randomized controlled trials are required to confirm our findings.

Long-term changes in renal function outcomes following radical cystectomy and urinary diversion

We analyzed long-term changes in the renal function of patients undergoing radical cystectomy and urinary diversion (UD). This study included 169 patients who underwent radical cystectomy and UD (42, cutaneous ureterostomy; 40, ileal conduit; 87, neobladder substitution), and were followed for at least 60 months (median 106 months). Renal deterioration was defined as a >25 % decrease in the estimated glomerular filtration rate (eGFR) relative to that prior to surgery. We determined the associations between several parameters and postoperative renal deterioration. Despite the significantly younger age and more favorable renal function of patients with neobladder substitution than of those with other types of UD, no significant differences were observed in the remaining preoperative clinical parameters among the three different UD groups. The mean eGFR of the 169 patients decreased from 69.6 to 55.9 mL/min/1.73 m(2), and renal deterioration was observed in 24 (57.1 %), 20 (50.0 %) and 34 (39.0 %) patients in the cutaneous ureterostomy, ileal conduit and neobladder substitution groups, respectively. Multivariate analysis of several parameters identified the presence of baseline hypertension and an episode of acute pyelonephritis, but not the type of UD, as significant predictors of postoperative renal deterioration. The incidence of renal deterioration was comparatively high following radical cystectomy, irrespective of the type of UD. Special attention should be paid to the long-term preservation of renal function in these patients, particularly those with hypertension and/or episodes of acute pyelonephritis.