Lower Baseline Renal Function Research Articles

Impact of worsening renal function in patients with incident heart failure across the spectrum of ejection fraction: a population-based longitudinal study

Abstract Background Renal dysfunction is a common occurrence in patients with heart failure (HF) and may impact on HF treatment and outcomes. HF clinical trial data suggest that worsening renal function (WRF) is associated with worse prognosis, however many of the medications used in HF cause a short-term decline in renal function that may improve in the longer-term. The real-world incidence and implications of WRF following an initial diagnosis of HF across the spectrum of ejection have not been well-characterised. Purpose The present study was designed to establish the incidence and outcomes associated with WRF in patients with incident HF on the risk of mortality and HF hospitalisation (hHF) in a real-world setting. Methods Electronic health records were linked to echocardiography data between 2016 to 2021 to define incident HF with reduced/mildly reduced/preserved EF (HFrEF/HFmrEF/HFpEF). Incidence of WRF at 6 months was determined as a composite endpoint of (i) having two consecutive eGFR declined by 40% or greater; (ii) having an eGFR <15 mL/min/1.73m^2; (iii) on sustained dialysis; or (iv) receiving kidney transplantation. Incidence of hHF and all-cause mortality were compared in HF patients with versus without WRF. We performed a stratified analysis according to baseline renal function (eGFR: >60, 45-59, 30-44, 15-29, or <15 mL/min/1.73m2). Results 4254 individuals were identified, 1100 HFrEF, 650 HFmrEF, 1252 HFpEF, and 1252 HF with unknown EF. Within 6 months of HF diagnosis, 592 patients died and 349 had WRF. Baseline eGFR <60 was present in 32% of individuals with HFrEF, 32% in HFpEF, 27% in HFmrEF, and 37% in HF with unknown EF. The incidence of WRF was similar in HFrEF (20.7 [95% CI: 16.9 – 25.1] per 100 person-years) and in HF with unknown EF (20.9 [17.1 – 25.3]), but was significantly lower in HFmrEF (13.6 [9.8 – 18.4]) and HFpEF (16.8 [13.7 – 20.5]). Patients with WRF were more likely to be female (adjusted hazard ratio [aHR]: 1.32 [1.06 – 1.64], p=0.014), having diabetes (1.34 [1.07 – 1.69], p = 0.012), and with lower baseline renal function (eGFR categories 45-59, 30-44, 15-29, or <15 compared with >60: aHR 1.75 [1.29 – 2.38], p<0.001; 1.64 [1.12 – 2.42], p=0.012; 5.65 [4.06 – 7.87], p<0.001; 90.74 [63.2 – 130.28], p<0.001). Individuals with WRF had significantly higher incidence of subsequent hHF (HR adjusted for age, sex, baseline renal function, and diabetes: 1.79 [1.35 – 2.39], p<0.001) and all-cause death (2.18 [1.66 – 2.88], p<0.001), compared to those without WRF. This was driven by patients diagnosed with HFrEF (2.46 [1.45 – 4.18], p<0.001) or HFpEF (3.45 [2.21 – 5.40], p<0.001), but was not seen in HFmrEF (1.91 [0.91 – 3.99], p=0.086) or HF within unknown EF (1.28 [0.65 – 2.52], p=0.484). Conclusion WRF is an important and common consequence following initial diagnosis of HF across the spectrum of EF with associated severe clinical outcomes in HF. Priority should be given to prevention of WRF in patients with incident HF.Impact of WRF on Clinical Outcomes

Abstract 17389: Sex Differences in Aortic Dissection Outcomes in the Houston Aortic Collaborative Experience

Background: Data on sex-related differences in presentation, management, and clinical outcome in acute aortic dissection (AAD) are sparse, especially for acute type A (AAAD) and acute type B (ABAD) subtypes. Aims: To determine the effect of sex on AAD presentation, management and outcomes in a large cohort of patients from two major aortic surgery centers. Methods: We retrospectively reviewed the two-institution clinical data of all consecutive patients treated for AAD from 2000 to 2022. Data were analyzed by univariate and multivariable methods for short- and long-term data using SAS 9.4. Cox multivariable analyses were restricted to 3 years’ follow-up to avoid violating the proportional-hazards assumption. Results: Overall, 1,855 patients treated for AADs with 1,109 AAAD and 746 ABAD. Median age was 60 years (IQR:50-70); 620 (33%) were women. Women were older (64 vs 58 yrs; P<.001), had lower baseline renal function (36% vs 26%, p<.001) and more genetically triggered aortic disease (11% vs 7%, P=.002). Clinical presentation is shown in Table. Women had fewer renal (17% vs 24%; P=.001), bleeding (10% vs 14%; P=.01), and GI (22% vs 26%; P=.048) in-hospital complications. 30-day mortality was not different between groups (12% vs 14%; P=.271). There was no significant difference in mid or long-term survival by sex overall, however, stratified analysis showed lower survival for women with AAAD, notably in the first 3 years (Figure). Among AAAD cases, absolute risk difference attributable to COPD in stratified analysis was 17% in women (p<.01), but numbers are small (n=63). Multivariable risk factors for 3 year mortality were female (HR 1.3, p<.016), GFR<60 (HR 1.4, p<.003), rupture (HR 2.0, p<.001), CAD (HR 1.8, p<.001), mesenteric MPS (HR 2.1, p<.001). Conclusions: Women with AAD presented at an older age with poor baseline renal function and had higher prevalence of genetic disease and ABAD. 3-year adjusted survival for women with AAAD was worse than men; COPD may modify risk by sex.

PD44-12 RISK FACTORS OF CHRONIC KIDNEY DISEASE DETERIORATION FOLLOWING RADICAL CYSTECTOMY FOR BLADDER CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD44-12 RISK FACTORS OF CHRONIC KIDNEY DISEASE DETERIORATION FOLLOWING RADICAL CYSTECTOMY FOR BLADDER CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS Alireza Ghoreifi, Reza Sari Motlagh, Takafumi Yanagisawa, Austria, Inderbir Gill, Siamak Daneshmand, Hooman Djaladat, and Shahrokh F Shariat Alireza GhoreifiAlireza Ghoreifi More articles by this author , Reza Sari MotlaghReza Sari Motlagh More articles by this author , Takafumi YanagisawaTakafumi Yanagisawa More articles by this author , Austria Austria More articles by this author , Inderbir GillInderbir Gill More articles by this author , Siamak DaneshmandSiamak Daneshmand More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , and Shahrokh F ShariatShahrokh F Shariat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003354.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The literature lacks high level of evidence regarding renal function changes and related contributing factors following radical cystectomy (RC). The aim of this study was to evaluate the potential risk factors of renal function deterioration in patients with bladder cancer undergoing RC. METHODS: PubMed, Web of Science, Cochrane Library, and Scopus databases were searched for articles published by September 2022 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. After quality and risk of bias assessments, eligible studies were included in the meta-analysis. The primary outcome was renal function deterioration following RC, which was defined as significant (≥10%) decline of estimated glomerular filtration (eGFR) rate and/or any chronic kidney disease (CKD) upstaging. In addition, subgroup meta-analyses were conducted in patients with pre-operative CKD stages 2 and 3a (eGFR 60-89 and 45-59 mL/min, respectively). RESULTS: A total of 10 articles, comprising 15,502 patients, were deemed eligible for this study. On meta-analysis of the whole cohort, factors that were associated with renal function deterioration following RC included older age (HR 1.03 per year, 95% CI 1.02–1.04), lower baseline renal function (HR 1.22, 95% CI 1.06–1.4), higher Charlson comorbidity index (HR 1.5, 95% CI 1.05–2.13), diabetes mellitus (HR 1.27, 95% CI 1.06–1.53), hypertension (HR 1.24, 95% CI 1.12–1.36), postoperative hydronephrosis (HR 1.69, 95% CI 1.22–2.33), and uretero-enteric stricture (HR 1.92, 95% CI 1.42–2.60). The results of the subgroup analyses in CKD stages 2 and 3a are shown in Table 1. CONCLUSIONS: Older age, lower baseline renal function, higher Charlson comorbidity index, diabetes mellitus, hypertension, postoperative hydronephrosis, and ureteroenteric stricture are significant risk factors of CKD deterioration following radical cystectomy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1129 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alireza Ghoreifi More articles by this author Reza Sari Motlagh More articles by this author Takafumi Yanagisawa More articles by this author Austria More articles by this author Inderbir Gill More articles by this author Siamak Daneshmand More articles by this author Hooman Djaladat More articles by this author Shahrokh F Shariat More articles by this author Expand All Advertisement PDF downloadLoading ...

Specificity of severe AKI aetiology and care in the elderly. The IRACIBLE prospective cohort study.

Acute Kidney Injury (AKI) is increasingly common in people over 65years of age, but its causes and management are poorly described. The purpose of this study was to describe the causes, management and prognosis of patients over 65 hospitalised for severe acute kidney injury (AKI) in all departments of a tertiary centre. The prospective IRACIBLE(IRA: AKI in French; CIBLE: target in French)cohort included 480 patients hospitalised at a university hospital over 18months for severe AKI or subgroup of AKIN3 (Acute Kidney Injury Network classification) defined by an acute creatinine increase > 354μmol/L or managed with acute renal replacement therapy (RRT). The history, aetiology of AKI, management, and prognosis were compared in three age groups: < 65, 65-75, and > 75years. The study population included 480 subjects (73% men) with a median body mass index (BMI) of 26.6kg/m2 [23.3, 30.9], 176 (37%) diabetic patients, 124 (26%) patients < 65years, 150 (31%) 65-75years and 206 (43%) > 75years. Increasing age class was associated with more comorbidities, a significantly lower median estimated glomerular filtration rate (eGFR) 6months before inclusion (82;62;46ml/min/1.73 m2, p < 0.05) and aetiology of AKI, which was more often obstructive (12%;15%;23%, p = 0.03) or part of a cardio-renal syndrome (6%;9%;/15%, p = 0.04). Older patients were less often managed in the intensive care unit (54%;47%;24%, p < 0.0001), wereless frequently treated byRRT (52%;43%;31%, p < 0.001) and receivedfewer invasive treatments (6%;9%;22%, p < 0.0001). Older survivors returned home less often (80%;73%;62%, p = 0.05) in favour of transfers to rehabilitation services (10%;13%;22%) with higher mortality at 3months (35%;32%;50%, p < 0.0001). Older patients hospitalised for severe AKI have a specific profile with more comorbidities, lower baseline renal function, an aetiology of AKI of mainly extra-parenchymal causes and a complex pathway ofcare with an overall poor prognosis.

Impact of sterile leukocyturia on outcome of critically ill patients with severe acute kidney injury.

The role of immunological mechanisms on renal regeneration and functional recovery after an episode of Acute Kidney Injury (AKI) is still understudied. We aim to evaluate the impact of sterile leukocyturia on outcomes of critically-ill AKI patients. A retrospective analysis of critically-ill patients with stage ≥2 AKI by KDIGO was performed. Patients with urinary tract infection, previous renal replacement therapy, chronic kidney disease stage >3 and kidney, urinary tract or prostatic cancer were excluded. Sterile leukocyturia was defined as a positive leukocyte esterase value. 108 patients with stage ≥2 AKI were included, 39.8% of which had sterile leukocyturia. AKI patients with sterile leukocyturia were older, had more cardiovascular disease and a lower baseline renal function (p<0.05). They had a higher serum creatinine and leukocytosis at admission, were more frequently septic (p<0.05) and had more persistent AKI by both KDIGO criteria at multivariable analysis (OR 6.130, 95% CI 2.007-18.747). Sterile leukocyturia was associated with different patient baseline and AKI characteristics and more persistent AKI by both KDIGO criteria. Sterile leukocyturia may represent a surrogate marker of renal inflammation during AKI.

Delayed Fever and Acute Kidney Injury in Patients with Urinary Tract Infection.

The presence of fever has long been a warning sign of severe urinary tract infection (UTI). However, we previously identified that inpatients with afebrile UTI had an increased risk of developing acute kidney injury (AKI). After expanding this cohort, 1132 inpatients with UTI diagnosed between January 2006 and April 2019 were analyzed. Overall, 159 (14%) of these patients developed AKI; bacteremia, urolithiasis, septic shock, hypertension, lower baseline renal function, marked leukocytosis, and the absence of fever were independently linked to AKI. When we further studied the cohort of inpatients with fever during hospitalization, we identified a group of “delayed fever” UTI inpatients who did not have fever as their initial presentation. Compared to patients presenting with fever at the emergency department, patients with delayed fever tended to be younger and have less frequent infection with Escherichia coli, more frequent AKI, upper tract infection, and a longer hospital stay. Despite the initial absence of fever, these patients demonstrated larger extents of elevations in both serum white blood cell counts and C-reactive protein levels. In short, besides UTI patients with lower baseline renal function that remain afebrile during their hospital stay, clinical awareness of the increased incidence of AKI in younger patients with “delayed fever” should also be noted.

SO052EFFECT OF SEVERE RENAL IMPAIRMENT OR END-STAGE RENAL DISEASE ON THE PHARMACOKINETICS AND PHARMACODYNAMICS OF ROXADUSTAT, AN ORAL HYPOXIA-INDUCIBLE FACTOR PROLYL HYDROXYLASE INHIBITOR

Abstract Background and Aims Roxadustat is an orally active hypoxia-inducible factor prolyl hydroxylase inhibitor used at titrated doses to treat anaemia in CKD patients. This study investigated the pharmacokinetics (PK), metabolic profile, pharmacodynamics, and safety of roxadustat in subjects with different degrees of renal function (RF). Method This was a phase 1, open-label study conducted in Germany and the United Kingdom (EudraCT Number: 2015-002565-28). Subjects were enrolled in four RF groups: normal RF (eGFR ≥90 mL/min/1.73 m2); severely impaired RF (not on dialysis; eGFR &amp;lt;30 mL/min/1.73 m2); end-stage renal disease (ESRD) on continuous ambulatory or automated peritoneal dialysis (CAPD/APD); or ESRD on 4-hour haemodialysis or haemodiafiltration (HD/HDF). Subjects in the normal RF, severely impaired RF, and ESRD on CAPD/APD groups received a single dose of 100-mg oral roxadustat on Day 1. A single-sequence design with two treatment periods (P1/P2) separated by a washout period was used for subjects with ESRD on HD/HDF; a single administration of 100-mg oral roxadustat occurred 2 hours after completion of a HD/HDF session (P1) and 2 hours before initiation of a HD/HDF session, 2 days after the previous session (P2). Plasma and urine PK of roxadustat and its circulating metabolites (O-glucuronide-, O-glucoside-, and sulphate of hydroxy-roxadustat) and plasma erythropoietin (EPO) were evaluated. Continuous heart rate monitoring was conducted. Results Of 73 screened subjects, 34 (46.6%) were enrolled and received roxadustat (normal RF, n=12; severely impaired RF, n=9; ESRD on CAPD, n=1; ESRD on HD/HDF, n=12). The geometric least-square mean ratio of area under the plasma concentration-time curve (AUC) from administration to infinity (AUCinf) relative to subjects with normal RF was 223% (90% CI: 185, 268) and 195% (90% CI: 165, 229) in subjects with severely impaired RF and in those with ESRD on HD/HDF, respectively. Roxadustat’s maximum concentration (Cmax) and terminal elimination half-life (t1/2) were comparable between groups. The PK of roxadustat and its metabolites were not affected by HD/HDF. In subjects with normal RF, the amount of roxadustat excreted unchanged in urine was &amp;lt;1%; urinary excretion and renal clearance of roxadustat and its metabolites decreased with lower baseline RF. Mean AUCinf and t1/2 for roxadustat’s circulating metabolites were higher in subjects with severely impaired RF and with ESRD on HD/HDF than in those with normal RF. Metabolite to parent ratio of AUCinf was &amp;lt;1% for O-glucuronide- and O-glucoside-roxadustat and &amp;lt;10% for sulphate of hydroxy-roxadustat. EPO baseline-corrected AUC from administration to last measurable concentration and EPO maximum effect were higher in subjects with severely impaired RF or with ESRD on HD/HDF than in those with normal RF. Conclusion The AUC for roxadustat and its metabolites was higher in patients with severely impaired RF or with ESRD on HD/HDF than in those with normal RF. Roxadustat’s Cmax and t1/2 were comparable among all groups. Roxadustat and its metabolites were not significantly cleared by HD/HDF.

The Effect of Donor Age and Recipient Characteristics on Renal Outcomes in Patients Receiving Prolonged-Release Tacrolimus After Liver Transplantation: Post-Hoc Analyses of the DIAMOND Study.

BackgroundThe DIAMOND study of de novo liver transplant patients showed that prolonged-release tacrolimus exposure in the acute post-transplant period maintained renal function over 24 weeks of treatment. To assess these findings further, we performed a post-hoc analysis in patients according to baseline kidney function, Model for End-stage Liver Disease [MELD] scores, and donor age.Material/MethodsPatients received prolonged-release tacrolimus (initial-dose, Arm 1: 0.2 mg/kg/day, Arm 2: 0.15–0.175 mg/kg/day, Arm 3: 0.2 mg/kg/day delayed until Day 5), mycophenolate mofetil and 1 steroid bolus. Arms 2 and 3 also received basiliximab. The recommended tacrolimus target trough levels to Day 42 post-transplantation were 5–15 ng/mL in all arms. In this post-hoc analysis, change in renal outcome, based on estimated glomerular filtration rate (eGFR), Modified Diet in Renal Disease-4 (MDRD4), values from baseline to Week 24 post-transplantation, were assessed according to baseline patient factors: eGFR (≥60 and <60 mL/min/1.73 m2), MELD score (<25 and ≥25) and donor age (<50 and ≥50 years).ResultsBaseline characteristics were comparable (Arms 1–3: n=283, n=287, n=274, respectively). Patients with baseline renal function, eGFR ≥60 mL/min/1.73 m2, experienced a decrease in eGFR in all tacrolimus treatment arms. In patients with lower baseline renal function (eGFR <60 mL/min/1.73 m2), an advantage for renal function was observed with both the early lower-dose and delayed higher-dose tacrolimus regimens compared with the early introduction of higher-dose tacrolimus. At Week 24, renal function was higher in the early-lower tacrolimus arm with older donors, and the delayed higher-dose tacrolimus arm with younger donors, both compared with early higher-dose tacrolimus.ConclusionsPre-transplantation factors, such as renal function and donor age, could guide the choice of prolonged-release tacrolimus regimen following liver transplantation.

Exposure to contrast media in the perioperative period confers no additional risk of acute kidney injury in surgical patients.

Iodinated contrast media (CM) used in angiography and computed tomography (CT) scans is an important cause of acute kidney injury (AKI) in hospitalized patients undergoing surgery. Contrast-induced nephropathy leads to AKI soon after CM administration. The aim of the study was to determine whether the timing of contrast media exposure related to diagnostic imaging during the immediate perioperative period influences the risk of post-operative AKI. All patients aged 18years or above who underwent diagnostic imaging within 7 days of non-cardiac surgery between 1 January 2003 and 31 December 2013 in the Tayside region of Scotland, UK were included in the analysis. The primary outcome of AKI was defined using the Kidney Disease: Improving Global Outcomes creatinine-based criteria. Multiple logistic regressions were performed to identify predictors for AKI. Of 9300 patients, 6224 were exposed to CM in the immediate perioperative period and 3076 were not. Post-operative AKI occurred in 678 (10.9%) of the 6224 patients who were exposed to CM. On multiple logistic regression, independent predictors of post-operative AKI were increasing age, male gender, lower baseline renal function and treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Timing of CM exposure did not affect risk of developing AKI, odds ratio 0.972 (95% confidence interval 0.935-1.010), P = 0.146. For patients who have either just had or are soon to undergo general surgical procedures there appears to be no need to limit CT scan quality by avoiding the administration of CM. These patients may benefit from the increased diagnostic utility of contrast-enhanced CT scans without increasing their risk of perioperative AKI.

Dialysis Following Transcatheter Aortic Valve Replacement: Risk Factors and Outcomes: An Analysis From the UK TAVI (Transcatheter Aortic Valve Implantation) Registry

ObjectivesThis study sought to determine the risk factors for post-transcatheter aortic valve replacement (TAVR) dialysis and to determine the impact of pre-TAVR or post-TAVR dialysis on mortality. BackgroundTAVR is now established as an alternative treatment to surgical aortic valve replacement. Data examining the impact of dialysis on outcomes after TAVR are lacking. MethodsThe UK TAVI (Transcatheter Aortic Valve Implantation) Registry was established to report outcomes on all TAVR procedures performed within the United Kingdom (2007 to 2014). Data were collected prospectively on 6,464 patients with a median follow-up of 625 days. ResultsThe proportion of patients on dialysis before TAVR has remained constant at 1.8%. After TAVR, the proportion of patients newly needing dialysis after TAVR has fallen from 6.1% (2007 to 2008) to 2.3% (2013 to 2014). The risk of new dialysis requirement after TAVR was independently associated with lower baseline renal function, year of procedure, impaired left ventricular function, diabetes, use of an Edwards valve, a nontransfemoral approach, need for open surgery, and moderate-to-severe aortic regurgitation after the procedure. Requirement for new dialysis after TAVR was associated with higher mortality at 30 days (hazard ratio: 6.44; 95% confidence interval: 4.87 to 8.53) and at 4 years (hazard ratio: 3.54; 95% confidence interval: 2.99 to 4.19; p < 0.001 for all) compared with patients without dialysis requirement. ConclusionsThe proportion of patients needing dialysis after TAVR has decreased over time. Post-TAVR dialysis is associated with increased mortality. Factors identified with dialysis requirement after TAVR require further investigation.

Is surgeon intuition equivalent to models of operative complexity in determining the surgical approach for nephron sparing surgery?

Introduction:The choice of approach for partial nephrectomy often depends on surgical complexity. We aimed to determine if surgeon intuition was equivalent to markers of operative complexity, such as RENAL nephrometry and Mayo adhesive probability (MAP) score, in determining the surgical approach for partial nephrectomy (PN).Materials and Methods:We retrospectively identified 119 masses removed for suspected renal cell carcinoma from January 2012 to September 2014 by a single surgeon who intuitively chose treatment with one of three surgical approaches: Open PN (OPN), robotic-assisted transperitoneal PN (RATPN), or robotic-assisted retroperitoneal PN (RARPN). Clinicodemographic characteristics, pathological features, and postoperative outcomes were compared for each approach. Logistic regression was performed to identify independent predictors of open surgical resection, our primary endpoint.Results:Fifty-four tumors (45%) were resected via OPN, 40 (34%) via RATPN, and 25 (21%) via RARPN. OPN was performed in patients with more comorbidities (P = 0.02), lower baseline renal function (P < 0.01), more solitary kidneys (P < 0.01), and more multifocal disease (P < 0.01). Patients undergoing OPN had higher median nephrometry scores compared to RATPN and RARPN patients (8 vs. 7 vs. 7, respectively; P = 0.03), but MAP scores were no different among all three groups (P = 0.36). On multivariate analysis, higher nephrometry scores (odds ratio: 1.41, 95% confidence interval: 1.10-1.81; P = 0.007) were independently associated with open surgical resection. Nephrometry score was predictive of OPN (area under curve = 0.64, P = 0.01) with a score of 6.5 having the highest sensitivity and specificity (76% and 42%, respectively).Conclusions:RENAL nephrometry score was associated with surgical approach intuitively chosen by an experienced surgeon, but the presence of adherent perinephric fat did not correlate with decision-making.

Indications, Techniques, Outcomes, and Limitations for Minimally Ischemic and Off-clamp Partial Nephrectomy: A Systematic Review of the Literature

ContextOn-clamp partial nephrectomy (PN) has been considered the standard approach to minimize intraoperative bleeding and thus achieve adequate control of tumor margins. The potential negative impact of ischemia on renal function (RF) led to the development of techniques to minimize or avoid renal ischemia, such as off-clamp PN and minimally ischemic PN techniques. ObjectiveTo review current evidence on the indications and techniques for and outcomes of minimally ischemic and off-clamp PN. Evidence acquisitionA systematic review of English-language publications on PN without a main renal artery clamp from January 2005 to July 2014 was performed using the Medline, Embase, and Web of Science databases. Evidence synthesisThe searches retrieved 52 papers. Off-clamp PN has been more commonly applied to small and peripheral renal tumors, while minimally ischemic PN is best suited for hilar and medially located renal tumors. These approaches are associated with increased intraoperative blood loss and perioperative transfusion rates compared to on-clamp PN. Minimally ischemic and off-clamp PN have potential functional benefits when longer ischemia time is anticipated, particularly for patients with lower baseline RF. Limitations include the lack of prospective randomized trials comparing minimally ischemic and off-clamp to on-clamp techniques, and the small sample size and short follow-up of most published series. The impact of different resection and renorrhaphy techniques on postoperative RF and its assessment via renal scintigraphy requires further investigations. ConclusionsMinimally ischemic and off-clamp PN are established procedures that may be particularly applicable for patients with decreased baseline RF. However, these techniques are technically demanding, with potential for increased blood loss, and require considerable experience with PN surgery. The role of ischemia in patients with a contralateral healthy kidney and consequently an indication for elective minimally ischemic or off-clamp PN remains a debatable issue. Patient summaryIn this review we analyzed available evidence on minimally ischemic and off-clamp partial nephrectomy. These techniques, although technically demanding, may be particularly applicable for patients with decreased baseline renal function.

Extrarenal atherosclerotic disease blunts renal recovery in patients with renovascular hypertension

Atherosclerotic renovascular disease (ARVD) is associated with high rates of coronary events and predicts mortality among patients with coronary artery disease (CAD). However, the impact of coronary atherosclerosis on renal outcomes after revascularization of ARVD is unclear. We hypothesized that CAD negatively impacts renal functional outcomes among patients with ARVD undergoing renal artery revascularization. Patients with ARVD who underwent echocardiography at Mayo Clinic, Rochester, Minnesota, USA between 2004 and 2012 were identified retrospectively and included if they had ejection fraction more than 50%. Renal and overall outcomes were compared among atherosclerotic renovascular disease patients with coronary artery disease (ARVD-C, n = 75) and without coronary artery disease (ARVD, n = 56), within 1 year from initial revascularization and included blood pressure control, renal function, and incident cardiovascular/cerebrovascular events. Degree of renal artery stenosis was similar in both groups. ARVD-C had higher prevalence of diabetes, peripheral artery disease (PAD), and cerebrovascular disease, and lower baseline renal function. Risk of developing end-stage renal disease was higher in ARVD-C (11 vs. 2%, P = 0.05). Despite better control of blood pressure and cholesterol levels, renal function postrevascularization worsened in 15% of ARVD-C compared with 2% of ARVD (P = 0.01). Differences in clinical outcomes remained statistically significant after adjustment for covariables, including sex, baseline blood pressure, renal function, underlying diabetes, cholesterol levels, and medications. Similar differences in clinical outcomes were also associated with PAD and cerebrovascular disease. CAD in patients with ARVD is a predictor of worse outcomes after renal revascularization, likely reflecting diffuse atherosclerotic disease. Further studies are needed to develop strategies to manage patients with vascular comorbidities and improve their outcomes.

Clofarabine-associated acute kidney injury in patients undergoing hematopoietic stem cell transplant

We examined clofarabine pharmacokinetics and association with renal toxicity in 62 patients participating in a phase I–II study of clofarabine–melphalan–alemtuzumab conditioning for hematopoietic stem cell transplant (HSCT). Pharmacokinetic parameters, including clofarabine area under the concentration–time curve (AUC), maximum concentration and clearance, were measured, and patients were monitored for renal injury. All patients had normal pretreatment creatinine values, but over half (55%) experienced acute kidney injury (AKI) after clofarabine administration. Age was the strongest predictor of AKI, with older patients at greater risk (p = 0.002). Clofarabine AUC was higher in patients who developed AKI, and patients with the highest dose-normalized AUCs experienced the most severe grades of AKI (p = 0.01). Lower baseline renal function, even when normal, was associated with lower clofarabine clearance (p = 0.008). These data suggest that renal-adjustment of clofarabine dosing should be considered for older and at-risk patients even when renal function is ostensibly normal.

Early hospital readmissions post‐kidney transplantation are associated with inferior clinical outcomes

Unplanned hospital readmissions are common early post-kidney transplantation. We investigated the relationship between early hospital readmissions and clinical outcomes in a single-center retrospective study that included all adult kidney transplant patients between 2004 and 2008 with follow-up to December 2012. The early hospital readmissions within the first 30d were numbered and the diagnosis ascertained. Patients were grouped as none, once, and twice or more readmissions. Predictors of early readmissions were assessed, and clinical outcomes and patient and death-censored kidney survival were compared. Among 1064 patients, 203 (19.1%) patients had once and 83 (7.8%) patients had twice or more readmissions within 30d. Surgical complications, infections, and acute kidney injuries/acute rejection were three most common diagnoses. The length of initial hospital stay and African American race were among the variables associated significantly with readmissions. Patients with early readmissions had lower baseline renal function (p<0.01) and more early acute rejection (p<0.01). During follow-up, only frequent readmissions, twice or more, within 30d were associated with increased risk of death (AHR 1.75, p=0.01) and death-censored kidney failure (AHR 2.20, p<0.01). Frequent early hospital readmissions post-transplantation identify patients at risk for poor long-term outcomes, and more studies are needed to understand the mechanisms.

PD35-12 PREOPERATIVE FACTORS ASSOCIATED WITH COMPLICATIONS FOLLOWING RADICAL NEPHROURETERECTOMY

You have accessJournal of UrologyBladder Cancer: Upper Tract Tumors I1 Apr 2014PD35-12 PREOPERATIVE FACTORS ASSOCIATED WITH COMPLICATIONS FOLLOWING RADICAL NEPHROURETERECTOMY Kuan Lin, Erik Lehman, Laura-Maria Krabbe, Vitaly Margulis, Tobias Klatte, Shahrokh Shariat, Alex Arnouk, Costas Lallas, Edouard Trabulsi, Gregory Bozzini, Pierre Colin, Sarah Drouin, Morgan Roupret, Benoit Peyronnet, Karim Bensalah, Kari Bailey, David Canes, and Jay Raman Kuan LinKuan Lin More articles by this author , Erik LehmanErik Lehman More articles by this author , Laura-Maria KrabbeLaura-Maria Krabbe More articles by this author , Vitaly MargulisVitaly Margulis More articles by this author , Tobias KlatteTobias Klatte More articles by this author , Shahrokh ShariatShahrokh Shariat More articles by this author , Alex ArnoukAlex Arnouk More articles by this author , Costas LallasCostas Lallas More articles by this author , Edouard TrabulsiEdouard Trabulsi More articles by this author , Gregory BozziniGregory Bozzini More articles by this author , Pierre ColinPierre Colin More articles by this author , Sarah DrouinSarah Drouin More articles by this author , Morgan RoupretMorgan Roupret More articles by this author , Benoit PeyronnetBenoit Peyronnet More articles by this author , Karim BensalahKarim Bensalah More articles by this author , Kari BaileyKari Bailey More articles by this author , David CanesDavid Canes More articles by this author , and Jay RamanJay Raman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2425AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical nephroureterectomy (RNU) is the gold standard for managing upper-tract urothelial carcinoma (UTUC). Perioperative complications may be significant given their impact on survival outcomes as well as potential delivery of adjuvant therapies when necessary. We review a multi-institutional, international cohort of patients undergoing RNU to define the incidence of perioperative complications as well as preoperative risk factors associated with these events. METHODS A retrospective review of institutional databases from 8 academic centers in the United States and Europe identified 732 patients who underwent RNU. Data on preoperative clinical, demographic, and comorbidity indices were collected. Complications occurring in these patients within 30-days of surgery were graded using the modified Clavien-Dindo scale. Univariate and multivariate analyses determined the association between preoperative variables and presence of complications. RESULTS 371 men and 361 women with median age of 70 years and BMI of 27 were included. Three-quarters of the cohort were Caucasian. Measurement of comorbidity indices noted median Charlson score of 4 (range, 1-14), while 44% had ASA ≥ 3 and 11% had ECOG status ≥ 2. Leading comorbid medical conditions included hypertension (55%), hyperlipidemia (41%), coronary artery disease (24%), diabetes (17%), and pulmonary disease (14%). Median baseline eGFR (CKD-EPI) was 58 ml/min/1.73m2 with 50% of the cohort having CKD stage ≥ III. Overall, 270 patients (37%) experienced a post-operative complication including 54 with Clavien III or greater events. On univariate analysis, patient age, race, baseline eGFR, comorbidities (diabetes, hyperlipidemia, hypertension) and all comorbidity indices (Charlson, ECOG, ASA) were associated with post-RNU complications. In a multivariate model including these variables, only patient age (OR 4.0, 95% CI 1.7 - 6.3, p=0.05), Charlson index (OR 4.5, 95% CI 2.1 - 6.8, p=0.03) and baseline eGFR (OR 7.8, 95% CI 3.4 - 12.1, p=0.005) were independently associated with post-operative complications. CONCLUSIONS Almost 40% of patients in our international cohort experienced a complication within 30 days of RNU. Increasing age, higher Charlson score, and lower baseline renal function were independently associated with patients developing complications. These metrics should be determined prior to surgery and may guide patient counseling and surgical expectations for the post-operative period. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e895 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Kuan Lin More articles by this author Erik Lehman More articles by this author Laura-Maria Krabbe More articles by this author Vitaly Margulis More articles by this author Tobias Klatte More articles by this author Shahrokh Shariat More articles by this author Alex Arnouk More articles by this author Costas Lallas More articles by this author Edouard Trabulsi More articles by this author Gregory Bozzini More articles by this author Pierre Colin More articles by this author Sarah Drouin More articles by this author Morgan Roupret More articles by this author Benoit Peyronnet More articles by this author Karim Bensalah More articles by this author Kari Bailey More articles by this author David Canes More articles by this author Jay Raman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

GW24-e3928 Endovascular chimney technique versus fenestrated endovascular aneurysm repair of juxtarenal abdominal aortic aneurysms

ObjectivesTo compare early outcomes of endovascular repair of juxtarenal abdominal aortic aneurysms (JAAAs) using the chimney technique with fenestrated endovascular aneurysm repair (FEVAR) in anatomically-matched patients.MethodsBetween January 2008 and December...

Predictive factors of chronic kidney disease stage V after partial nephrectomy in a solitary kidney: a multi-institutional study

ObjectivePartial Nephrectomy (PN) in a solitary kidney is at risk of chronic kidney disease (CKD) stage V and/or haemodialysis (HD). Our objective was to determine predictive factors of CKD stage V in this population. Material & MethodsData from 300 patients were retrospectively collected from 16 tertiary centres. Clinical and operative parameters, tumor characteristics and renal function before surgery were analyzed. Patients with and without CKD stage V (defined as MDRD<15ml/min) were compared using χ2 and Student-t tests for qualitative and quantitative variables, respectively. Predictive factors of CKD stage V were evaluated with a multivariable analysis using a Cox regression model. ResultsMedian age and BMI were 63 years old and 26kg/m², respectively. Most of the patients (65%) were male with an anatomic solitary kidney (88.3%). Median tumor size was 4cm and 98% were malignant tumors. Median operative time, blood loss and clamping time were 180min, 350ml and 20min respectively. Renal cooling was used in 19.3% and clamping of the pedicle was performed in 61.6%. Twenty five patients (8.5%) presented post operative CKD stage V at last follow-up and 18 underwent HD (6%) post-operatively because of acute renal insufficiency. There was no difference between CKD stage V and non CKD stage V patients concerning Charlson index, operative time (180min vs 179min, p = 0.39), blood loss (475ml vs 350ml, p = 0.51), use of renal cooling and type of clamping. Patients with CKD stage V were older (70 vs 63 years old, p = 0.005), had a lower baseline renal function (clearance MDRD 41 vs. 62ml/min, p<0.0001) and an increased tumor size (p = 0.02). Complications occurred in 91 patients (30%) with 16% of minor (Clavien 1–2) and 14% of major (Clavien > 2) complications, respectively. In multivariable analysis, baseline MDRD, BMI, and the occurrence of a minor complication were independent predictive factors of post operative CKD stage V. ConclusionPN in a solitary kidney is at risk of post-operative CKD stage V and HD. Pre-operative altered renal function and post operative complications are the main predictive factors of permanent CKD stage V.

Former Smoking Is a Risk Factor for Chronic Kidney Disease After Lung Transplantation

Chronic kidney disease (CKD) is a common complication after lung transplantation (LTx). Smoking is a risk factor for many diseases, including CKD. Smoking cessation for >6 months is required for LTx enlistment. However, the impact of smoking history on CKD development after LTx remains unclear. We investigated the effect of former smoking on CKD and mortality after LTx. CKD was based on glomerular filtration rate (GFR) ((125) I-iothalamate measurements). GFR was measured before and repeatedly after LTx. One hundred thirty-four patients never smoked and 192 patients previously smoked for a median of 17.5 pack years. At 5 years after LTx, overall cumulative incidences of CKD-III, CKD-IV and death were 68.5%, 16.3% and 34.6%, respectively. Compared to never smokers, former smokers had a higher risk for CKD-III (hazard ratio [HR] 95% confidence interval [95%CI]= 1.69 [1.27-2.24]) and IV (HR = 1.90 [1.11-3.27]), but not for mortality (HR = 0.99 [0.71-1.38]). Adjustment for potential confounders did not change results. Thus, despite cessation, smoking history remained a risk factor for CKD in LTx recipients. Considering the increasing acceptance for LTx of older recipients with lower baseline renal function and an extensive smoking history, our data suggest that the problem of post-LTx CKD may increase in the future.

Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms

To compare early outcomes of endovascular repair of juxtarenal and suprarenal aneurysms using the chimney technique with open repair in anatomically-matched patients. Between January 2008 and December 2009, 21 patients underwent endovascular repair of juxtarenal and suprarenal aortic aneurysms with chimney stenting (Ch-EVAR) of 1 or 2 renal and/or superior mesenteric artery (SMA) vessels. These were compared with 21 anatomically-matched patients that underwent open repair (OR) during the same time period. Primary end points were 30-day mortality, chimney stent patency, and type Ia endoleak. Secondary end points included early complications, renal function, blood loss, and length of stay (LOS). Despite a higher proportion of women, oxygen-dependent pulmonary disease and lower baseline renal function, 30-day mortality was identical with one death (4.8%) in each group. Blood loss and total LOS were significantly less for Ch-EVAR. Six patients (29%) in the chimney group had acute kidney injury (AKI) compared with the open group, in which there were one (4.8%) AKI and four (19%) acute renal failures, of which two (9.5%) required chronic hemodialysis. Renal function at 12 months demonstrated similar declines in the overall estimated glomerular filtration rate (eGFR) in the Ch-EVAR and OR groups (11.1 ± 19.6 vs 10.4 ± 25.2, P = NS, respectively). There was one asymptomatic SMA stent occlusion at 6 months and partial compression of a second SMA stent which underwent repeat balloon angioplasty. Primary patency at 6 and 12 months was 94% and 84%, respectively. There was one type Ia endoleak noted at 30 days which resolved by 6 months. Ch-EVAR may extend the anatomical eligibility of endovascular aneurysm repair using conventional devices. It appears to have similar mortality to open repair with less morbidity. Long-term durability and stent patency remain to be determined.