Long-term Renal Function Research Articles

Early conversion to belatacept-based immunosuppression regimen promotes improved long-term renal graft function in kidney transplant recipients

BackgroundBelatacept has been demonstrated as an effective alternative immunosuppressant in kidney transplant recipients. This study focuses on outcomes of early and late conversion to Belatacept-based immunosuppression after kidney transplant. Materials and methodsThis retrospective analysis of a prospectively collected database included all adult kidney transplants patients at SUNY Upstate Medical Hospital from 1 January 2014 to 30 December 2022. Early conversion was defined as all conversions done at <6 months after kidney transplantation, and late conversion to belatacept was defined as conversion at >6 months after kidney transplantation. ResultsOut of 61 patients included in this study, 33 patients (54%) were in the early conversion group, and 28 patients (46%) were in the late conversion group. The mean eGFR in the early conversion group was 26.73 ± 16.26 ml/min/1.73 m2 before conversion to belatacept, which improved to 45.3 ± 21.01 ml/min/1.73 m2 at one-year post-conversion (p = 0.0006). Furthermore, eGFR changes in the late conversion group were insignificant, with 46.30 ± 15.65 ml/min/1.73 m2 before conversion to belatacept, and 44.76 ± 22.91 ml/min/1.73 m2 after one year of follow-up (p = 0.72). All four biopsy-proven allograft rejections in the early conversion group were acute T-cell-mediated rejections (ATMR). In the late conversion group, out of three biopsy-proven rejections, one was chronic antibody-mediated rejection (CAMR), one was ATMR, and one was mixed ATMR/CAMR. All four patients with ATMR rejection received mycophenolic acid (MPA) as part of their immunosuppressive regimen, and none received tacrolimus. The one-year post-conversion allograft survival rate in early and late conversion groups was 100%. However, the one-year post-conversion patient survival rate was 90.9% in the early conversion group and 100% in the late conversion group (P = 0.11). ConclusionsEarly post-transplant conversion to belatacept can improve the eGFR more meaningful when compared to late conversion. Patients who receive belatacept and MPA rather than tacrolimus may have increased rates of T-cell-mediated rejection.

Evaluation of Protein Creatinine Ratio as A Marker for Proteinuria among Children Recovered From Hypernatremia: A Longitudinal Observational Study

Background: Proteinuria is one of the many markers of kidney damage. An increased protein creatinine ratio (Pr/Cr ratio) is known to have both diagnostic and prognostic value in detecting renal damage. The previous observational study revealed that children with hypernatremia are at risk of developing acute kidney injury (AKI), which positively correlates with recovery from hypernatremia. Detection of high Pr/Cr ratio in the spot urine samples is a predictor for proteinuria. However, there is lack of evidence for whether or not renal damage persists in children who recovered from hypernatremia. Therefore, we aimed to evaluate the long-term renal function of the children who had recovered from hypernatremia.&#x0D; Methodology: The study was an observational longitudinal study conducted in Dhaka Hospital of icddr,b from March 2016 to March 2017. The objective of this study was to evaluate the renal function of children 12 months after recovering from hypernatremia. All these children in this cohort study were brought to Dhaka Hospital of icddr,b for a spot urine analysis to evaluate their kidney function.&#x0D; Results: Among the 224 children who recovered from hypernatremia 143 (64%) children’s mothers gave consent to participate in follow-up study. Half of the study children demonstrated to have a raised urinary Pr/Cr ratio. However, majority of them did not have any evidence associated with urinary problems. Proteinuria was comparable in different types of hypernatremic children. After adjusting for potential co-variates like age, sex, any form of malnutrition, severity of hypernatremia and co-morbidity, 86% of children from better socioeconomic family are less likely to have high urinary Pr/Cr ratio in comparison with those from poorest households. Regression analysis also revealed that children who were less than 36 months of age are 2 times more likely to have raised urinary Pr/Cr ratio than those more than 36 months old (Odds Ratio 2.31(1.06, 5.02); p 0.035).&#x0D; Conclusion: Children from low socioeconomic households and below 36 months of age are more likely to have proteinuria after recovering from hypernatremia. However further study is required to correlate the high Pr/Cr ratio with other parameters to rule out the long-term effect of hypernatremia on renal function.&#x0D; Bioresearch Commu. 9(2): 1270-1275, 2023 (July)

#2955 THE IMPACT OF SARS-COV-2 INFECTION ON LONG-TERM RENAL FUNCTION IN PATIENTS WITH GLOMERULAR DISEASES

Abstract Background and Aims We sought to evaluate the long-term effects of SARS-CoV-2 infection on renal function in patients with glomerular diseases. Method A total of 451 patients with biopsy-proven glomerular disease and at least 12 months of follow-up after COVID-19 pandemic onset were included in the study. A SARS-CoV-2 infection was diagnosed based on a positive RT-PCR and/or antigen test. Multivariate Cox proportional hazards regression analysis was performed to identify the independent predictors of a composite endpoint (≥30% decline in eGFR, ESRD). In addition, a multivariate linear regression analysis was developed to identify the impact of SARS-CoV-2 infection on eGFR decline at 12 months after pandemic onset. Results Since 26th February 2020, when the first case of SARS-CoV-2 infection was diagnosed in Romania, 23.1% of patients had a SARS-CoV-2 infection during a follow-up period of 2.5 y (0.8-2.6). The most frequent glomerular disease was IgA nephropathy (22.6%), followed by lupus nephritis (11.5%) and membranous nephropathy (9.5%). 71.8% of the study cohort received various regimens of immunosuppression. Patients with SARS-CoV-2 infection were younger and more likely to have received immunosuppressive therapy compared to patients without infection, but the renal function at baseline was similar between the study groups (eGFR, 52±31.2 vs 52.1±29.3 ml/min, respectively; p = 0.78). 17.6% of patients reached the composite endpoint, while 12.3% progressed to ESRD. Those with SARS-CoV-2 infection were more likely to reach the composite endpoint compared to those without infection [prevalence of composite endpoint, 26.7% vs. 14.8%, p = 0.006; OR, 2.1 (95%CI, 1.23-3.58), p = 0.006) (Figure 1). Similarly, there was a significant decline of eGFR in the first year of follow-up between the two study groups [-2.24 (-24.8; 20.9) vs. +2.31 (-16.8; 27.5) ml/min, respectively, p = 0.004]. In multivariate Cox proportional hazards regression analysis, the independent predictors of the composite endpoint were baseline eGFR (HR, 0.94; 95%CI, 0.92-0.95, p&amp;lt;0.001), the occurrence of SARS-CoV-2 infection (HR, 1.91; 1.16-3.12, p = 0.01) and male gender (HR, 1.64; 95%CI, 1.01-2.66, p = 0.04). When taking into account the severity of SARS-CoV-2 infection, a severe infection was the most important predictor of the composite endpoint (HR, 2.1; 95%CI, 1.02-4.29, p = 0.04) (Figure 2). The results remained consistent when restricting the analysis to ESRD as an endpoint. When taking into account the eGFR slope at 12 months after COVID-19 pandemic onset as the outcome variable in multivariate linear regression analysis, the SARS-CoV-2 infection occurrence independently determined a reduction of eGFR by 4.62 ml/min/1.73m2 (β coefficient, -4.62; 95%CI, -7.74 to -1.5, p = 0.004). Conclusion There is a significant impact of SARS-CoV-2 infection on long-term renal function in patients with glomerular diseases, while those with severe infection had a greater decline of eGFR and a worse renal survival.

#3701 MESANGIAL C3 DEPOSITION ASSOCIATES WITH CHRONIC LESIONS AND RENAL OUTCOME IN PATIENTS WITH IGA NEPHROPATHY

Abstract Background and Aims Mesangial C3 deposition is frequently observed in patients with IgA nephropathy (IgAN). We sought to investigate whether the extent of mesangial C3 deposition predicts long-term renal function. Method We conducted a retrospective, observational study that included all patients with biopsy-proven IgAN between 1999 and 2021 and a follow-up period of at least 12 months. All renal biopsy specimens were reviewed and scored according to the 2016 revised Oxford Classification by two independent pathologists. In addition, mesangial C3 deposits were assessed by immunofluorescence (IF) staining of C3 deposition and scored semi-quantitatively as: absent, mild (1+), moderate (2+) and intense (3+). The study composite endpoint was defined as doubling of serum creatinine or ESRD, whichever came first. Results 197 patients were followed for a median of 51.7 months (IQR:19.9-84.3 months). The mean eGFR and median 24-hour proteinuria were 54.4 ± 31.3 ml/min/1.73 m2 and 1.5 g/day (IQR: 0.8-3.35), respectively. 29.9% of the patients reached the composite endpoint. The percentage of patients with M1, E1, S1, T1 and T2 were 77.2%, 24.4%, 57%, 27.9% and 16.8%, respectively. 13.7% of patients showed crescents in less than 25% of glomeruli (C1), while 6.6% of them had over 25% of glomeruli involved (C2). In terms of mesangial C3 deposits, 7.7% had absent, 9.5% mild, 19.6% moderate and 63.1% intense IF staining. Compared to patients with mild-moderate or absent C3 staining on IF, those with intense C3 staining had more frequently M1 (83% vs. 73.5% vs. 38.5%, p = 0.04), S1 (64.2% vs. 49% vs. 30.8%, p = 0.03) and T1-2 (51.9% vs. 32.6% vs. 7.7%, p = 0.01). Similarly, the percentage of global glomerulosclerosis was significantly higher in patients with intense C3 staining (20.7% vs. 12.5% vs. 0%, p = 0.04). In terms of clinical variables, patients with intense C3 staining had a greater degree of proteinuria [1.8 (IQR: 0.9-3.6) vs. 1.2 (0.6-2.1) vs. 0.5 (IQR: 0.1-4.9), p = 0.04] and a tendency for a worse kidney function at baseline (52 ± 32 vs. 58 ± 32 vs. 66 ± 40 ml/min, p = 0.3). There was a tendency for patients with mesangial C3 deposits to have an increased serum IgA level, but the extent of deposits did not correlate with serum C3 level. Regarding the renal outcome, there was a significantly higher proportion of patients with intense C3 deposition to have a doubling of serum creatinine (23.6% vs. 12.2% vs. 0%, p = 0.05) and a tendency for a worse composite endpoint (35.8% vs. 22.4% vs. 23.1%, p = 0.1). Accordingly, the odds ratio for doubling of serum creatinine and for the composite endpoint in patients with intense C3 deposition were 2.88 (95%CI, 1.11-7.47, p = 0.02) and 1.91 (95%CI, 0.94-3.91, p = 0.07), respectively. Conclusion In our study, the extent of mesangial C3 deposition associated with clinical variables and chronic lesions of MESTC score. In addition, identification of intense C3 staining on IF could predict a worse renal outcome in patients with IgA nephropathy.

Assessing the Trade-off Between the Safety and Effectiveness of Off-clamp Robotic Partial Nephrectomy for Renal Masses with a High RENAL Score: A Propensity Score–matched Comparison of Perioperative and Functional Outcomes in a Multicenter Analysis

BackgroundTumors with a high nephrometry score represent a challenging surgical scenario for which robotic partial nephrectomy (RPN) is a primary option in expert hands. ObjectiveTo compare perioperative and functional outcomes of off-clamp and on-clamp RPN in patients with renal masses with a high RENAL score (≥9). Design, setting, and participantsFor this retrospective analysis, an RPN data set including 1604 patients treated at three institutions between 2003 and 2021 was queried for cases with a RENAL score ≥9. Outcome measurements and statistical analysisWe used 1:1 propensity score matching (PSM) to select a cohort in which imbalances between the off-clamp and on-clamp groups were minimized. We used χ2 and Student t tests to compare categorical and continuous variables, respectively. The Kaplan-Meier method was used to compare the probability of having an estimated glomerular filtration rate (eGFR) ≥45 ml/min during follow-up. Univariable and multivariable analyses were performed to identify predictors of a trifecta outcome (negative surgical margin status, no Clavien-Dindo grade ≥3 complications, eGFR decline ≤30%) and of retaining eGFR ≥45 ml/min over time. Results and limitationsFrom an overall cohort of 354 patients (142 on-clamp, 212 off-clamp), a homogeneous PSM cohort of 78 patients in each group was selected (p ≥ 0.17). In the PSM cohort, operative time was significantly shorter in the off-clamp group (p < 0.001). There were no differences between the groups in the rates of severe complications (p = 0.32) and positive surgical margins (p = 0.24). The rate of trifecta achievement was significantly higher in the off-clamp group (83.3% vs 67.9%; p = 0.03). Warm ischemia time >20 min was independently negatively associated with trifecta achievement (odds ratio 0.32, 95% confidence interval 0.14–0.74). Moreover, the off-clamp group had a significantly higher probability of retaining eGFR ≥45 ml/min over time (3 yr: 95.9% vs 81.6%; p = 0.03); every 1-min increase in warm ischemia time reduced this probability by 1.3%. ConclusionsWe found a favorable trade-off between the benefits and risks of off-clamp RPN, with similar perioperative outcomes and a net benefit in terms of trifecta achievement and long-term renal function outcomes in comparison to on-clamp RPN. Patient summaryThe complexity of surgery for kidney tumors can be assessed using the RENAL score, which is a measure of the location and size of a kidney tumor. In a multicenter series of patients with tumors with a high RENAL score, we compared outcomes between strategies with (on-clamp) and without (off-clamp) clamping of kidney blood vessels during robot-assisted removal of part of the affected kidney. We found that off-clamp surgery results in better postoperative kidney function.

Sequential afferent and sympathetic renal denervation impact on cardiovascular and renal homeostasis in the male Sprague-Dawley rat

Renal denervation (RDNx) is emerging as a promising treatment for cardiovascular disease, yet the underlying mechanisms and contributions of afferent (sensory) and efferent (sympathetic) renal nerves in healthy conditions remains limited. We hypothesize that sympathetic renal nerves contribute to long-term MAP and renal function, whereas afferent renal nerves do not contribute to the maintenance of cardiovascular and renal function. To test this hypothesis, we performed two experiments. In experiment one, we performed total renal denervation (T-RDNx), ablating afferent and sympathetic renal nerves, in normotensive adult SD rats to determine effects on MAP and renal function. Experiment 2 employed a sequential surgical ablation using: (1) afferent targeted renal denervation (A-RDNx), then (2) sympathetic (T-RDNx) denervation to determine the individual contributions to cardiovascular and renal homeostasis. In experiment 1, MAP decreased following T-RDNx and GFR increased. In experiment 2, A-RDNx led to an increase in MAP but did not change renal function. In contrast, T-RDNx decreased MAP and improved renal filtration. Together, these data partially support our hypothesis that renal sympathetic nerves contribute to the chronic regulation of arterial pressure and renal function. Contrary to the hypothesis, A-RDNx produced an increase in MAP without a detected change in renal function. We concluded that renal sympathetic nerves influence MAP and renal function regulation through a well-defined tonic contribution to renal vascular resistance and sodium reabsorption, whereas afferent renal nerves likely contribute to the maintenance of MAP through a tonic sympatho-inhibitory, negative feedback regulation in the normotensive, healthy rat.

Voiding and renal function 10 years after radical cystectomy and orthotopic neobladder in women.

To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence. Women who underwent RC and ONB reconstruction between 1995 and 2011 were included in this study. Patients who developed disease failure or were lost to follow-up were excluded. The study outcomes were long-term voiding function and the incidence and predictors of RF deterioration (defined as >20% decline of baseline). Analysis was performed using the log-rank test and Cox regression analysis. The study included 195 patients with a median (interquartile range) follow-up of 98 (53-151) months, of whom 95 had >10 years of follow-up. Daytime continence, night-time continence and chronic urine retention (CUR) were identified in 170 (87%), 134 (69%) and 52 patients (27%), respectively. Among patients with >10 years of follow-up, 82 (86%), 66 (70%) and 31 (33%) had daytime continence, night-time continence and CUR at the last follow-up visit, respectively. RF deterioration events occurred in 74 patients throughout the follow-up and chronic kidney disease (CKD) stage III-V developed in 80 patients. Patients' age (hazard ratio [HR] 1.41, 95% confidence interval [CI]1.06-1.89; P = 0.02) and serous-lined extramural tunnel diversion (HR 0.43, 95% CI 0.19-0.86; P = 0.02) were the independent predictors of RF deterioration. Among patients with >10 years of follow-up, RF deteriorated in 46 patients (49%) and CKD stage III-V developed in 40 (42%). Women surviving more than 10 years after RC and ONB maintained acceptable continence status, apart from having a higher CUR rate, compared to those followed for <10 years. However, RF deterioration developed in nearly half of them.

Long-term renal function in patients undergoing surgical reconstruction for tubercular cicatrized bladder.

We evaluated the long-term renal function in patients after surgical reconstruction for tuberculous contracted bladder (TBC) and determined factors associated with decreased renal function (RF) during follow up. We reviewed the records of 61 patients who underwent augmentation cystoplasty (AC) or orthotopic neobladder (ONB) for TBC between June 1994 and August 2019 in our institute. The estimated glomerular filtration rate (eGFR) was calculated preoperatively at initial presentation, before augmentation and at various intervals during follow up. Renal function decrease was defined as a defined as new-onset stage-3A Chronic kidney disease(CKD) or upstaging of pre-operative CKD stage 3A in follow-up. Multivariable analysis was done to evaluate the association of clinicopathological features and postoperative complications with decreased renal function. We analyzed 39 patients who had a minimum follow-up of 1-year post reconstruction. At a median follow-up of 52months (IQR 31-103months), 16/39 patients developed RF decrease. In univariate analyses, initial eGFR, and associated ureteric stricture in contralateral renal unit were significantly associated with new-onset renal insufficiency (p < 0.001 each). On multivariable analysis, only initial presenting eGFR (p < 0.001) was an independent predictor of new-onset renal insufficiency. ROC cut-off levels for eGFR at presentation predicting the primary end point of RF decrease was 45ml/min. Decreased renal function is noted in most patients during long term follow-up after surgical reconstruction for TBC. After controlling for preoperative and postoperative risk factors, patients with initial presenting GFR < 45ml/min are at greater risk of a decline in renal function following reconstruction.

Risks and benefits of partial nephrectomy performed with limited or with zero ischaemia time.

To test the hypothesis that longer warm ischaemia time (WIT) might have a marginal impact on renal functional outcomes and might, in fact, reduce haemorrhagic risk intra-operatively. Data from 1140 patients treated with elective partial nephrectomy (PN) for a cT1-2 cN0 cM0 renal mass were prospectively collected. WIT was defined as the duration of clamping of the main renal artery with no refrigeration and was tested as a continuous variable. The primary outcome of the study was evaluation of the effect of WIT on renal function (estimated glomerular filtration rate [eGFR]) postoperatively, at 6 months and in the long term (measured between 1 and 5 years after surgery). The secondary outcome of the study was haemorrhagic risk, defined as estimated blood loss (EBL) or peri-operative transfusions. Multivariable linear, logistic and Cox regression analyses, accounting for age, Charlson comorbidity index, clinical size, preoperative eGFR and year of surgery, were used and the potential nonlinear relationship between WIT and the study outcomes was modelled using restricted cubic splines. A total of 863 patients (76%) underwent PN with WIT and 277 (24%) without. The baseline median eGFR was 87.3 (68.8-99.2) mL/min/1.73m2 for the on-clamp population and 80.6 (63.2-95.2) mL/min/1.73m2 for the off-clamp population. The median duration of WIT was 17 (13-21) min. At multivariable analyses predicting renal function, longer WIT was associated with decreased postoperative eGFR (estimate: -0.21, 95% confidence interval [CI] -0.31; -0.11 [P < 0.001]). Conversely, no association between WIT and eGFR was recorded at 6-month or long-term follow-up (all P > 0.8). At multivariable analyses predicting haemorrhagic risk, clampless resection with no ischaemia time and PN with short WIT was associated with an increased EBL (estimate: -21.56, 95% CI -28.33; -14.79 [P < 0.001]) and peri-operative transfusion rate (estimate: -0.009, 95% CI -0.01; -0.003 [P = 0.002]). No association between WIT and positive surgical margin status was recorded (all P = 0.1). Patients and clinicians should be aware that performing PN with very limited or even with zero WIT might increase bleeding and the need for peri-operative transfusion while not improving long-term renal function outcomes.

MP58-16 SIGNIFICANCE OF GLUCOSE CONTROL FOR PERIOPERATIVE AND LONG-TERM RENAL FUNCTIONS AFTER NEPHRON-SPARING SURGERY FOR RENAL CANCER IN PATIENTS WITH DIABETES

You have accessJournal of UrologyCME1 Apr 2023MP58-16 SIGNIFICANCE OF GLUCOSE CONTROL FOR PERIOPERATIVE AND LONG-TERM RENAL FUNCTIONS AFTER NEPHRON-SPARING SURGERY FOR RENAL CANCER IN PATIENTS WITH DIABETES Do Gyeong Lim, Jeong Hoon Oh, Jiwon Ryu, Seong Hyeon Yu, Ho Seok Chung, Kyung Jin Oh, Sun-Ouck Kim, Seung Il Jung, Taek Won Kang, Dong Deuk Kwon, Kwangsung Park, and Eu Chang Hwang Do Gyeong LimDo Gyeong Lim More articles by this author , Jeong Hoon OhJeong Hoon Oh More articles by this author , Jiwon RyuJiwon Ryu More articles by this author , Seong Hyeon YuSeong Hyeon Yu More articles by this author , Ho Seok ChungHo Seok Chung More articles by this author , Kyung Jin OhKyung Jin Oh More articles by this author , Sun-Ouck KimSun-Ouck Kim More articles by this author , Seung Il JungSeung Il Jung More articles by this author , Taek Won KangTaek Won Kang More articles by this author , Dong Deuk KwonDong Deuk Kwon More articles by this author , Kwangsung ParkKwangsung Park More articles by this author , and Eu Chang HwangEu Chang Hwang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003311.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This study aimed to evaluate the predictive factors for perioperative and long-term renal functions after nephron-sparing surgery (NSS). METHODS: The clinical records of 379 patients who underwent NSS for a single renal tumor with a normal contralateral kidney between 2009 and 2016 were retrospectively analyzed. After surgery, the occurrence of acute kidney injury (AKI) within 7 days and the progression of chronic kidney disease (CKD) 5 years later were assessed using serum creatinine (S-Cr) levels. Perioperative AKI was defined as an increase in the S-Cr level by ≥ 0.3 mg/dL or 1.5–1.9 times the baseline value. CKD was defined as the estimated glomerular filtration rate (eGFR) decreasing from > 60 mL/min/1.73 m2 to <60 mL/min/1.73 m2. RESULTS: Changes in the eGFR were assessed during 5 years after surgery. Among 379 patients, 81 (21.4%) patients presented diabetes mellitus (DM), and 30 (7.92%) experienced uncontrolled DM. The AKI occurrence and CKD progression were observed in 50 (13.2%) patients and 79 (20.8%) patients, respectively. Multivariate analyses revealed that female gender (odds ratio [OR] = 0.39, 95% confidence interval [CI]: 0.16–0.91, p=0.029), uncontrolled DM (OR=2.63, 95% CI: 1.05–6.60, p=0.039), and intermediate NePhRO score (OR=2.02, 95% CI: 1.07–3.80, p=0.03) were associated with perioperative AKI. In addition, old age (OR=1.14, 95% CI: 1.10–1.18, p<0.001) and uncontrolled DM (OR=4.57, 95% CI: 1.84–11.4, p=0.001) were associated with long-term CKD progression. CONCLUSIONS: Uncontrolled DM is the only predictive factor for perioperative and long-term renal functions after nephron-sparing surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e802 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Do Gyeong Lim More articles by this author Jeong Hoon Oh More articles by this author Jiwon Ryu More articles by this author Seong Hyeon Yu More articles by this author Ho Seok Chung More articles by this author Kyung Jin Oh More articles by this author Sun-Ouck Kim More articles by this author Seung Il Jung More articles by this author Taek Won Kang More articles by this author Dong Deuk Kwon More articles by this author Kwangsung Park More articles by this author Eu Chang Hwang More articles by this author Expand All Advertisement PDF downloadLoading ...

MP58-13 FUNCTIONAL OUTCOMES AFTER SURGERY IN PATIENTS WITH RENAL CANCER AND TUMOR THROMBUS

MP58-13 FUNCTIONAL OUTCOMES AFTER SURGERY IN PATIENTS WITH RENAL CANCER AND TUMOR THROMBUS

MP47-12 SINGLE LAYER CORTICAL RENORRHAPHY AS A SAFE ALTERNATIVE TO DUAL LAYER RENORRHAPHY DURING ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP47-12 SINGLE LAYER CORTICAL RENORRHAPHY AS A SAFE ALTERNATIVE TO DUAL LAYER RENORRHAPHY DURING ROBOTIC PARTIAL NEPHRECTOMY Tarek El-Ghazaly, Jonathan Rosenfeld, Shilajit Kundu, Robert Nadler, and Kent Perry Tarek El-GhazalyTarek El-Ghazaly More articles by this author , Jonathan RosenfeldJonathan Rosenfeld More articles by this author , Shilajit KunduShilajit Kundu More articles by this author , Robert NadlerRobert Nadler More articles by this author , and Kent PerryKent Perry More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003293.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic partial nephrectomy (RPN) is being increasingly adopted in the management of renal masses amenable to nephron-sparing surgery. Robotic renorraphy techniques, including dual layer repairs, have carried over from laparoscopic partial nephrectomy (LPN) which was initially associated with higher bleeding and urine leak rates compared to open partial nephrectomy (OPN). Dual layer repair has been shown in previous studies to prolong warm ischemia time, while potentially leading to a higher rate of pseudoaneurysm formation and worse long term renal function parameters. Our aim is to compare single cortical robotic renorrhaphy (SCRR) to dual-layer robotic renorrhaphy (DLRR) in terms of bleeding rates secondary to pseudoaneurysm formation, urine leak rates, and long-term renal functional outcomes. METHODS: A prospectively maintained list of all RPN procedures at Northwestern Memorial Hospital from January 2018 to July 2022 was retrospectively reviewed. 247 RPNs were identified, including 71 cases with SCRR carried out, and 176 cases with DLRR. Preoperative imaging was used to calculate nephrometry scores using R.E.N.A.L. (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, location relative to polar lines, hilar) measurements. Charts of patients with a length of stay longer than 72 hours, or with any readmissions under the urology service were closely examined for bleeding or leakage complications. Other examined parameters included drain fluid-to-serum creatinine ratios, as well as short term and long term changes in glomerular filtration rates (GFR). RESULTS: Comparing SCRR to DLRR, similar nephrometry scores were seen across both groups undergoing RPN (6.6 vs 7, p=0.29), including equivalent tumor sizes (34 mm vs 30 mm, p=0.11) and nearness to the collecting system (p=0.25). No significant differences in rates of bleeding secondary to pseudoaneurysms (0.03% vs 0.02%, p=0.8), urine leak rates (0% vs 0%), or changes in GFR (p=0.25) were seen between both groups of this study. CONCLUSIONS: No significant changes in urine leakage or bleeding rates secondary to pseudoaneurysm formation or changes in renal functions were found when comparing SLRR to DLRR during RPN for masses of equivalent sizes, depth and nephrometry scores. Single layer cortical repair seems to offer a safe method of shortening renorrhaphy and warm ischemia times compared to dual layer repairs. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e648 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tarek El-Ghazaly More articles by this author Jonathan Rosenfeld More articles by this author Shilajit Kundu More articles by this author Robert Nadler More articles by this author Kent Perry More articles by this author Expand All Advertisement PDF downloadLoading ...

MP56-14 LONG-TERM RENAL FUNCTION IN PATIENTS UNDERGOING TRIMODAL THERAPY FOR BLADDER CANCER

You have accessJournal of UrologyCME1 Apr 2023MP56-14 LONG-TERM RENAL FUNCTION IN PATIENTS UNDERGOING TRIMODAL THERAPY FOR BLADDER CANCER Affan Zafar, Linda Nguyen, Alexandra Hunter, William Shipley, Niall Heney, Anthony Zietman, Matthew Wszolek, Jason Efstathiou, Michael Drumm, Hannah Roberts, and Adam Feldman Affan ZafarAffan Zafar More articles by this author , Linda NguyenLinda Nguyen More articles by this author , Alexandra HunterAlexandra Hunter More articles by this author , William ShipleyWilliam Shipley More articles by this author , Niall HeneyNiall Heney More articles by this author , Anthony ZietmanAnthony Zietman More articles by this author , Matthew WszolekMatthew Wszolek More articles by this author , Jason EfstathiouJason Efstathiou More articles by this author , Michael DrummMichael Drumm More articles by this author , Hannah RobertsHannah Roberts More articles by this author , and Adam FeldmanAdam Feldman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003309.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Trimodal therapy (TMT) is a standard treatment option for select patients with muscle-invasive bladder cancer. The efficacy of TMT has been shown in several randomized trials; however, the long-term effect on renal function has not been investigated. Furthermore, various types of chemotherapy agents (ie. mitomycin, 5-FU, cisplatin) used during TMT are nephrotoxic. As many bladder cancer patients are elderly with significant medical comorbidities, data on long term renal function would aid in management. We sought to evaluate the change in renal function over 10 years in bladder cancer patients who have completed TMT. METHODS: The Massachusetts General Hospital’s institutional TMT database was retrospectively reviewed to obtain baseline renal function (estimated GFR) at time of muscle-invasive bladder cancer (MIBC) diagnosis. The eGFR values were calculated using the CKD-EPI creatinine equation. Interval eGFR was obtained for years 1, 3, 5, and 10 after the date of bladder cancer diagnosis. RESULTS: 287 patients undergoing TMT treatment for muscle invasive bladder cancer were reviewed. Patients were excluded due to incomplete TMT treatment or missing data, resulting in 251 eligible patients for evaluation of baseline mean eGFR. Median follow up was 4.56 years. Baseline mean eGFR was 65.67 mL/min/1.73. Mean eGFR for years 1, 3, 5, and 10 were 58.43 mL/min/1.73, 55.4 mL/min/1.73, 54.54 mL/min/1.73, and 57.3 mL/min/1.73, respectively. CONCLUSIONS: Renal function for bladder cancer patients undergoing TMT declined slightly after 1 year of follow up but remained stable for the remainder of the 10 years of follow up. Further studies are needed to identify predictors of renal decline and compare these results with the overall bladder cancer and general population. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e780 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Affan Zafar More articles by this author Linda Nguyen More articles by this author Alexandra Hunter More articles by this author William Shipley More articles by this author Niall Heney More articles by this author Anthony Zietman More articles by this author Matthew Wszolek More articles by this author Jason Efstathiou More articles by this author Michael Drumm More articles by this author Hannah Roberts More articles by this author Adam Feldman More articles by this author Expand All Advertisement PDF downloadLoading ...

Long-Term Renal Function after Catheter Ablation of Atrial Fibrillation.

Background: Atrial fibrillation (AF) is associated with the development and progression of chronic kidney disease (CKD). This study evaluated the impact of long-term rhythm outcome after catheter ablation (CA) of AF on renal function. Methods and results: The study group included 169 consecutive patients (the mean age was 59.6 ± 10.1 years, 61.5% were males) who underwent their first CA of AF. Renal function was assessed by eGFR (using the CKD-EPI and MDRD formulas), and by creatinine clearance (using the Cockcroft-Gault formula) in each patient before and 5 years after index CA procedure. During the 5-year follow-up after CA, the late recurrence of atrial arrhythmia (LRAA) was documented in 62 patients (36.7%). The mean eGFR, regardless of which formula was used, significantly decreased at 5 years following CA in patients with LRAA (all p < 0.05). In the arrhythmia-free patients, the mean eGFR at 5 years post-CA remained stable (for the CKD-EPI formula: 78.7 ± 17.3 vs. 79.4 ± 17.4, p = 0.555) or even significantly improved (for the MDRD formula: 74.1 ± 17.0 vs. 77.4 ± 19.6, p = 0.029) compared with the baseline. In the multivariable analysis, the independent risk factors for rapid CKD progression (decline in eGFR > 5 mL/min/1.73 m2 per year) were the post-ablation LRAA occurrence (hazard ratio 3.36 [95% CI: 1.25-9.06], p = 0.016), female sex (3.05 [1.13-8.20], p = 0.027), vitamin K antagonists (3.32 [1.28-8.58], p = 0.013), or mineralocorticoid receptor antagonists' use (3.28 [1.13-9.54], p = 0.029) after CA. Conclusions: LRAA after CA is associated with a significant decrease in eGFR, and it is an independent risk factor for rapid CKD progression. Conversely, eGFR in arrhythmia-free patients after CA remained stable or even improved significantly.

Involution of unilateral multicystic dysplastic kidney: Long term data from a single centre

Unilateral multicystic dysplastic kidney (MCDK) is congenital anomaly which can be detected by ultrasound during antenatal period. The reported rate of MCDK ranges between 1 in 2,200 to 1 in 4,300 live births. This study was aimed to assess the determinants associated with the MCDK with follow-up until teens to evaluate the evolution of the disorder. This was an observational longitudinal study, involution degrees were observed following the baseline measurement of the size of the MCDK as documented on postnatal ultrasound, and long-term complications and renal function were also recorded. A total of 350 patients were identified, while 90 patients fulfilled the criteria of the study and completed the study duration of 10 years. Out of which 19 (21.1%) patients reported involution of MCDK size during follow-up as complete and partial, 7 (7.7%) within first year of age, 5 (5.5%) during first 2 years and 7 (7.7%) within 4 years of age. Large-sized MCDK at the time of diagnosis is less likely to involute through the first decade of life. However, conventional treatment is rational with the absence of complications.

Nadir creatinine as a predictor of renal outcomes in PUVs: A systematic review and meta-analysis.

Posterior urethral valves (PUVs) represent the most severe pediatric obstructive uropathy, responsible for chronic renal failure in up to 65% of cases and progression to end-stage kidney disease (ESKD) in about 8%-21% of patients. Unfortunately, renal outcomes have poorly improved over time. The key point is to identify patients at risk; thus, several prenatal and postnatal prognostic factors have been analyzed to improve clinical outcomes. Postnatal nadir creatinine seems to accurately predict long-term renal prognosis, but there is no definitive evidence to support this finding. We performed a systematic review with meta-analysis to analyze the predictive value of nadir creatinine on long-term renal function in infants with PUVs. We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and Cochrane Library were systematically searched for studies published from January 2008 to June 2022. All the articles were checked independently by two reviewers in two steps. A total of 24 articles were screened, and 13 were included for data extraction. Data from 1,731 patients with PUVs were analyzed, with a mean follow-up of 5.5 years; of these, on average, 37.9% developed chronic kidney disease (CKD) and 13.6% developed ESKD. All the articles evaluated nadir creatinine as a predictor of CKD, most using a level of 1 mg/dL, with statistical significance at the 5% level. The relative risk of developing CKD in patients with creatinine values higher than the nadir cutoff considered was 7.69 (95% CI: 2.35-25.17, I 2 = 92.20%, p < 0.001). Nadir creatinine is the best prognostic factor for long-term renal function in patients affected by PUV. A value above the cutoff of 1 mg/dL should be considered a significant predictor for the risk of CKD and ESKD. Further studies are needed to define different nadir creatinine cutoffs for better stratification of the different CKD stages and for the development of reliable scores, which include the association of several variables.

Increased frequency of CD39+CD73+ regulatory T cells and Deltex-1 gene expression level in kidney transplant recipients with excellent long-term graft function

BackgroundThe ability of regulatory T cells (Tregs) to limit inflammatory responses has been demonstrated. However, different subpopulations of this cell have varying abilities to suppress alloreactive immune responses. The primary goal of this study was to assess the frequency of CD4+FOXP3+CD39+CD73+ Tregs and Deltex-1 gene expression on long-term renal transplant function. MethodsA total of 49 subjects were divided into 3 groups: (i) the excellent long-term graft function (ELTGF) group, (ii) the chronic graft dysfunction (CGD) group, and (iii) the healthy control (HC) group. Following sample collection, peripheral blood mononuclear cells (PBMCs) were isolated, and the Deltex-1 gene expression level and the frequency of CD4+FOXP3+CD39+CD73+ Tregs were evaluated. ResultsThe ELTGF group had more CD4+FOXP3+ Tregs than the CGD group, but the difference was not statistically significant (P = 0.07). However, the frequency of CD4+FOXP3+CD39+CD73+ Tregs and the ratio of these cells to total CD4+ lymphocytes significantly increased in the ELTGF group than in the CGD group (P = 0.04 and P = 0.02 respectively). In addition, the expression level of the Deltex-1 gene was significantly lower in the CGD group than in the other 2 groups (P = 0.01 and P = 0.04 respectively). ConclusionsGiven the increased frequency of CD4+FOXP3+CD39+CD73+ Tregs and the expression level of the Deltex-1 gene in the ELTGF group, it appears that these factors probably improved function and long-term survival of the transplanted organ through the suppression of alloreactive responses and reduction of inflammation. In other words, one of the immunological mechanisms involved in the CGD group may be a deficiency in Tregs.

Acute kidney injury as an independent predicting factor for stage 3 or higher chronic kidney disease after nephrectomy.

The association between postoperative acute kidney injury (AKI) and long-term renal function after nephrectomy has not been fully explored, with accurate prognostic models in which AKI is an independent predicting variable still being absent. We conducted a retrospective study of 528 patients who underwent unilateral radical nephrectomy or partial nephrectomy owing to renal cell carcinoma between January 2013 and December 2016. Postoperative AKI was defined as an absolute increase in serum creatinine level by 0.3 mg/dl or ≥5 0% increase from the preoperative value within 48 hours after surgery. The endpoint was the time to the incident stage 3 or higher chronic kidney disease (defined as eGFR<60 ml/min/1.73m²), or any claim for initiation of dialysis. Cox proportional hazards regression analysis was conducted to construct the final model. Internal validation was performed using 10-fold cross-validation. The model was evaluated in discrimination by Harrell's C-index and area under curve (AUC) values, and calibration by calibration plots. Five hundred twenty-eight patients were finally enrolled in the study cohort, and the median follow-up period was 38 months. Among 528 admitted patients, 232 (43.9%) developed AKI, and stage 3 or higher CKD occurred in 47 (8.9%) patients during the follow-up time, with 33 in 47 patients (70.2%) having postoperative AKI. AKI was significantly correlated with poor prognosis of renal function (HR = 3.079, P < 0.001). After the adjustment of conventional predictors, AKI was still independently related to kidney function deterioration, and the correlation was influenced by the severity of AKI. Five variables were selected to establish the prognostic model, including age, surgery type, preoperative estimated glomerular filtration rate, preoperative blood urea nitrogen, and postoperative AKI. The model had good discrimination, with the Harrell's C-index of 0.92 (95% CI 0.89-0.95), and AUC values varying from 87.7 to 95.7 at different time points. AKI during the perioperative period is an independent predicting factor of stage 3 or higher CKD after nephrectomy.

Significance of Glucose Control for Perioperative and Long-Term Renal Functions after Nephron-sparing Surgery for Renal Cancer in Patients with Diabetes.

This study aimed to evaluate the predictive factors for perioperative and long-term renal functions after nephron-sparing surgery (NSS). The clinical records of 379 patients who underwent NSS for a single renal tumor with a normal contralateral kidney between 2009 and 2016 were retrospectively analyzed. After surgery, the occurrence of acute kidney injury (AKI) within 7 days and the progression of chronic kidney disease (CKD) 5 years later were assessed using serum creatinine (S-Cr) levels. Perioperative AKI was defined as an increase in the S-Cr level by ≥ 0.3 mg/dL or 1.5-1.9 times the baseline value. CKD was defined as the estimated glomerular filtration rate (eGFR) decreasing from > 60 mL/min/1.73 m2 to < 60 mL/min/1.73 m2. Changes in the eGFR were assessed during 5 years after surgery. Among 379 patients, 81 (21.4%) patients presented diabetes mellitus (DM), and 30 (7.92%) experienced uncontrolled DM. The AKI occurrence and CKD progression were observed in 50 (13.2%) patients and 79 (20.8%) patients, respectively. Multivariable analyses revealed that female gender (95% confidence interval [CI]: 0.16-0.91, odds ratio [OR] = 0.39, P = 0.029), uncontrolled DM (95% CI: 1.05-6.60, OR = 2.63, P = 0.039), and intermediate NePhRO score (95% CI: 1.07-3.80, OR = 2.02, P = 0.03) were associated with perioperative AKI. In addition, old age (95% CI: 1.10-1.18, OR = 1.14, P < 0.001) and uncontrolled DM (95% CI: 1.84-11.4, OR = 4.57, P = 0.001) were associated with long-term CKD progression. Uncontrolled DM is the only predictive factor for perioperative and long-term renal functions after nephron-sparing surgery.

The IRON Study: Investigation of Robot-assisted Versus Open Nephron-sparing Surgery

BackgroundCurrent literature does not provide large-scale data regarding clinical outcomes of robot-assisted (RAPN) versus open (OPN) partial nephrectomy. Moreover, data assessing predictors of long-term oncologic outcomes after RAPN are scarce. ObjectiveTo compare perioperative, functional, and oncologic outcomes of RAPN versus OPN, and to investigate the predictors of oncologic outcomes after RAPN. Design, setting, and participantsThis study included 3467 patients treated with OPN (n = 1063) or RAPN (n = 2404) for a single cT1–2N0M0 renal mass from 2004 to 2018 at nine high-volume European, North American, and Asian institutions. Outcome measurements and statistical analysisThe study outcomes were short-term postoperative, functional, and oncologic outcomes. Regression models investigated the effect of surgical approach (open vs Robot assisted) on study outcomes, and interaction tests were used for subgroup analyses. Propensity score matching for demographic and tumor characteristics was used in sensitivity analyses. Multivariable Cox-regression analyses identified predictors of oncologic outcomes after RAPN. Results and limitationsBaseline characteristics were similar between patients receiving RAPN and OPN, with only few differences. After adjusting for confounding, RAPN was associated with lower odds of intraoperative (odds ratio [OR]: 0.39, 95% confidence interval [CI]: 0.22, 0.68) and Clavien-Dindo ≥2 postoperative (OR: 0.29, 95% CI: 0.16, 0.50) complications (both p < 0.05). This association was not affected by comorbidities, tumor dimension, PADUA score, or preoperative renal function (all p > 0.05 on interaction tests). On multivariable analyses, we found no differences between the two techniques with respect to functional and oncologic outcomes (all p > 0.05). Overall, there were 63 and 92 local recurrences and systemic progressions, respectively, with a median follow-up after surgery of 32 mo (interquartile range: 18, 60). Among patients receiving RAPN, we assessed predictors of local recurrence and systemic progression with discrimination accuracy (ie, C-index) that ranged from 0.73 to 0.81. ConclusionsWhile cancer control and long-term renal function did not differ between RAPN and OPN, we found that the intra- and postoperative morbidity—especially in terms of complications—was lower after RAPN than after OPN. Our predictive models allow surgeons to estimate the risk of adverse oncologic outcomes after RAPN, with relevant implications for preoperative counseling and follow-up after surgery. Patient summaryIn this comparative study on robotic versus open partial nephrectomy, functional and oncologic outcomes were similar between the two techniques, with lower morbidity—especially in terms of complications—for robot-assisted surgery. The assessment of prognosticators for patients receiving robot-assisted partial nephrectomy may help in preoperative counseling and provides relevant data to tailor postoperative follow-up.