Postoperative Renal Function Impairment Research Articles

Comparison of off-clamp microwave scissors-based sutureless partial nephrectomy versus on-clamp conventional partial nephrectomy in a canine model.

To compare the usefulness and safety of off-clamp microwave scissors-based sutureless partial nephrectomy (MSPN) with on-clamp conventional partial nephrectomy (cPN) in dogs. We performed off-clamp MSPN using microwave scissors (MWS) in six dogs, and on-clamp cPN in three dogs, in two-stage experiments. The bilateral kidney upper poles were resected via a midline incision under general anesthesia. After 14 days of follow-up, the lower pole resections were performed. The renal calyces exposed during renal resections were sealed and transected using MWS in off-clamp MSPN and were sutured in on-clamp cPN. In the off-clamp MSPN group, the generator's power output of MWS was set as either 50 W or 60 W for each kidney side. We compared the procedure time (PT), ischemic time (IT), blood loss (BL), and normal nephron loss (NNL) between the two techniques using the Mann-Whitney U-test. We successfully performed 24 off-clamp MSPNs and 12 on-clamp cPNs. The off-clamp MSPN was significantly superior to on-clamp cPN in avoiding renal ischemia (median IT, 0 min vs. 8.6 min, p < 0.001) and reducing PT (median PT, 5.8 min vs. 11.5 min, p < 0.001) and NNL (median NNL, 5.3 mm vs. 6.0 mm, p = 0.006) with comparable BL (median BL, 20.9 ml vs. 23.2 ml, p = 0.804). No bleeding and major urine leakage were noted during the reoperations. Off-clamp MSPN outperforms on-clamp cPN in lowering the risks of postoperative renal function impairment in dogs.

Yeni Başlayan Böbrek Yetmezliğinin Endovasküler Aort Onarımı Yapılan Hastalarda Mortalite Oranlarına Etkisi

Abstract Background: Visceral organ blood circulation is seriously impaired in aortic pathologies especially aortic dissection involving descending thoracic and abdominal aorta. Herein, we aimed to determine the effect of the newly onset renal function impairment on postoperative mortality rates of the patients undergoing EVAR and TEVAR procedures. Methods: Patients who underwent an EVAR / TEVAR procedure in our clinic included in this retrospective study. Patients were divided into two groups according to the presence of renal function impairment. Mortality rates were calculated for the groups. Results: A total of 60 patients who underwent an EVAR/TEVAR procedure between November 2016 and May 2021 included in this study. Group 1 included a number of 48 (80%) patients without postoperative renal dysfunction. Group 2 included a total of 12 (20%) patients with postoperative renal function impairment. The initial analysis of the data revealed significant differences in the age and sex variables of the groups (P=0.038 and P=0.008 respectively). Then propensity score matching was performed to avoid bias in the groups. After propensity score matching Group 1 included 12 (50%) patients without postoperative renal impairment and Group 2 included 12 (50%) patients with postoperative renal dysfunction. There were no significant differences between the groups after propensity matching. Mortality rate was significantly different between the groups which was 1 patient (8.33%) in Group 1 vs 6 (50.00%) patients in Group 2 (P=0.020). Conclusions: Renal functions after EVAR/TEVAR procedures should be carefully monitored because renal impairment is closely related with postoperative mortality. We suggest that more studies with larger patient numbers should be conducted on the relation of renal functions and mortality after regularly performed EVAR/TEVAR procedures.

PD43-12 NEW 3D VIRTUAL MODELS WITH RENAL PERFUSION VOLUMES: OPTIMIZING THE CLAMPING STRATEGY DURING ROBOT-ASSISTED PARTIAL NEPHRECTOMY TO MINIMIZE THE POSTOPERATIVE RENAL INJURY

You have accessJournal of UrologyCME1 Apr 2023PD43-12 NEW 3D VIRTUAL MODELS WITH RENAL PERFUSION VOLUMES: OPTIMIZING THE CLAMPING STRATEGY DURING ROBOT-ASSISTED PARTIAL NEPHRECTOMY TO MINIMIZE THE POSTOPERATIVE RENAL INJURY Daniele Amparore, Federico Piramide, Alberto Piana, Sabrina DE Cillis, Paolo Verri, Giovanni Busacca, Marco Colombo, Martina Mandaletti, Enrico Checcucci, Cristian Fiori, and Francesco Porpiglia Daniele AmparoreDaniele Amparore More articles by this author , Federico PiramideFederico Piramide More articles by this author , Alberto PianaAlberto Piana More articles by this author , Sabrina DE CillisSabrina DE Cillis More articles by this author , Paolo VerriPaolo Verri More articles by this author , Giovanni BusaccaGiovanni Busacca More articles by this author , Marco ColomboMarco Colombo More articles by this author , Martina MandalettiMartina Mandaletti More articles by this author , Enrico CheccucciEnrico Checcucci More articles by this author , Cristian FioriCristian Fiori More articles by this author , and Francesco PorpigliaFrancesco Porpiglia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003353.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The aim of this study was to develop and test new 3D virtual models (3DVM) considering their different perfusion volumes instead of vascular regions empirically estimated, to evaluate their intraoperative accuracy in guiding selective clampings and to assess their impact on the renal function of the operated kidney. METHODS: We implemented our 3DVMs together with the Voronoi diagram, a Euclidean distance-based mathematical tool used to calculate vascular dominant regions in other organs. A perfusion volume-based 3DVM was built for all the renal masses scheduled for robot-assisted partial nephrectomy (RAPN) from 12/2019 to 09/2022. On its basis a selective or superselective clamping, limited to the peritumoral area, was planned and performed intraoperatively when feasible. To assess the functional impact of the clamping strategy on the operated kidney a sub-cohort of patients underwent baseline and 3 months postoperative renal scintigraphy (RS), evaluating the split renal function (SRF) and estimated renal plasmatic flow (ERPF). RESULTS: 103 patients were prospectively enrolled in the study. The median (IQR) number of kidney and tumor perfusion volumes were 8 (7-10) and 3 (2-3), respectively. In 79 patients (76.6%) a selective clamping was performed, for 16 (15.5%) patients the main artery was clamped, and 8 (7.8%) patients underwent clampless procedure. The median (IQR) ischemia time for global and selective clamping were 17 (15-25) and 16 (12-20) minutes, respectively. In the 51 patients underwent RS (Table 1), mean change in SRF rate decreased from 11.3% to 7.7% and 1.7% for global, selective (I order artery) and super-selective (II order artery) clamping, respectively (p=0.004). Similarly, mean change in ERPF rate diminished from 18.9% to 9.9% and 6.0% for the same category groups (0.02). CONCLUSIONS: The implementation of mathematical algorithms to 3DVMs allows a precise estimation of the kidney perfusion volumes, minimizing the extension of the ischemic region with the selective clamping and leading to reduce the postoperative renal function impairment. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1123 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniele Amparore More articles by this author Federico Piramide More articles by this author Alberto Piana More articles by this author Sabrina DE Cillis More articles by this author Paolo Verri More articles by this author Giovanni Busacca More articles by this author Marco Colombo More articles by this author Martina Mandaletti More articles by this author Enrico Checcucci More articles by this author Cristian Fiori More articles by this author Francesco Porpiglia More articles by this author Expand All Advertisement PDF downloadLoading ...

On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis.

Simple SummaryRobot-assisted partial nephrectomy is a viable option to treat tumors >7 cm. In this setting, however, the risk of postoperative renal function deterioration is higher because of the prolonged warm ischemia times (>20 min) that are required in two-thirds of cases, if an on-clamp approach is used. On the contrary, an off-clamp robotic partial nephrectomy is associated with shorter operation times and significantly improves the probabilities of achieving favorable perioperative outcomes.We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13–4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27–0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.

Impact of Trifecta definition on rates and predictors of "successful" robotic partial nephrectomy for localized renal masses: results from the Surface-Intermediate-Base Margin Score International Consortium.

Over the years, five different Trifecta score definitions have been proposed to optimize the framing of "success" in partial nephrectomy (PN) field. However, such classifications rely on different metrics. The aim of the present study was to explore how the success rate of robotic PN, as well as its drivers, vary according to the currently available definitions of Trifecta. Data from consecutive patients with cT1-2N0M0 renal masses treated with robotic PN at 16 referral centers from September 2014 to March 2015 were prospectively collected. Trifecta rate was defined for each of the currently available definitions. Multivariable logistic regression analysis was used to evaluate possible predictors of "Trifecta failure" according to the different adopted formulation. Overall, 289 patients met the inclusion criteria. Among the definitions, Trifecta rates ranged between 66.4% and 85.9%. Multivariable analysis showed that predictors for "Trifecta failure" were mainly tumor-related (i.e. tumor's nephrometry) for those Trifecta scores relying on WIT as a surrogate metric for postoperative renal function deterioration (definitions 1,2), while mainly surgery-related (i.e. ischemia time and excision strategy) for those including the percentage change in postoperative eGFR as the functional cornerstone of Trifecta (definitions 3-5). There was large variability in rates and predictors of "unsuccessful PN" when using different Trifecta scores. Further research is needed to improve the value of the Trifecta metrics, integrating them into routine patient counseling and standardized assessment of surgical quality across institutions.

Usefulness of the mayo adhesive probability score as a predictive factor for renal function deterioration after partial nephrectomy: a retrospective case-control study.

Whether the Mayo adhesive probability score, an index of the perinephric fat environment, could be a predictive factor for renal function deterioration after partial nephrectomy was investigated. A retrospective case-control study of 78 patients who underwent laparoscopic partial nephrectomy was performed. An estimated glomerular filtration rate preservation rate at ≤ 90% at 3months after surgery was defined as postoperative renal function deterioration. These patients were divided into two groups (non-deterioration and deterioration groups). Patient factors including Mayo adhesive probability scores (both tumor and unaffected sides) and surgical factors were evaluated to identify the predictors for postoperative renal function deterioration. The statistical analysis used univariate and multivariate logistic regression analyses. Thirty-seven (47.4%) patients had postoperative renal function deterioration after partial nephrectomy. Univariate analysis identified Mayo adhesive probability score on the unaffected side (p = 0.02), and warm ischemia time (p < 0.01) as predictors of postoperative renal function deterioration. On multivariate analyses, Mayo adhesive probability score on the unaffected side (odds ratio: 1.38 [1.05-1.79], p = 0.02) and warm ischemia time (odds ratio: 1.04 [1.01-1.07], p < 0.01) were significantly associated with postoperative renal function deterioration as same as univariate analysis. On receive operating characteristic curve analysis, Mayo adhesive probability score on the unaffected side (cutoff value 1.5; p = 0.02) and warm ischemia time (cutoff value 26.5min; p = 0.01) were significant predictors of renal function deterioration 3month after surgery. The Mayo adhesive probability score on the unaffected side and warm ischemia time are useful predictors for renal function deterioration after partial nephrectomy. 2019-249, January 21st, 2019, retrospectively registered.

Microvesicles derived from human umbilical cord mesenchyme promote M2 macrophage polarization and ameliorate renal fibrosis following partial nephrectomy via hepatocyte growth factor.

The intraoperative ischemia in partial nephrectomy (PN) often leads to postoperative renal function impairment and fibrosis, which can be regulated by macrophage polarization. We have previously demonstrated that microvesicles derived from human Wharton's Jelly mesenchymal stromal cells (hWJMSC-MVs) attenuated renal ischemia-induced renal fibrosis and contained a substantial quantity of hepatocyte growth factor (HGF). Herein, we investigated whether MSC-MVs regulate macrophage polarization and ameliorate renal fibrosis following ischemia-PN via transferring HGF. A rat model of ischemia-PN was established by 45min of left renal ischemia followed by removal of 1/3 upper left kidney. MSC-MVs were injected through the tail vein immediately after ischemia. Renal injury biomarkers were measured and histologic analysis was performed to analyze renal injury. A co-culture model of THP-1 macrophages and MSC-MVs was utilized. The expression of M1 markers and M2 markers were determined to evaluate macrophage polarization. MSC-MV administration significantly ameliorated renal inflammation, lesions, and fibrosis in ischemia-PN rats, and promoted M2 macrophage polarization both in rat remnant renal tissues and LPS-treated THP-1 cells. These effects of MSC-MVs were compromised when HGF expression was downregulated in MSC-MVs. Collectively, MSC-MVs promote M2 macrophage polarization and attenuate renal fibrosis following ischemia-PN via transferring HGF.

Predictors of poor neonatal outcomes in fetuses diagnosed with congenital urinary tract anomalie.

Urinary tract anomalies account for approximately one-quarter of all antenatally detected anomalies. The aim of this study was to identify factors associated with severe adverse neonatal outcomes of a prenatally diagnosed urinary tract anomaly. A retrospective-prospective study included 101 pregnant women with prenatally diagnosed fetal urinary tract anomalies presented to the Council for Fetal Anomalies. Prenatal diagnoses were compared with autopsy findings in cases of terminated pregnancy or with clinical and operative findings of the infants. The mortality rate in the group of patients with fetal obstructive uropathy (60 patients) was 10% and in the group of patients with fetal multicystic dysplastic kidney (38 patients) 15.7%. Surgery was performed on 53.4% of the children, whereas more than half of the operations involved resolving associated urinary tract anomalies. Postoperative renal function deterioration occurred in 19% of the children. The prognosis of renal function in obstructive uropathies is excellent if oligoamnios does not develop prenatally and in case of timely provided surgical care is provided postnatally. The finding of the bilateral multicystic dysplastic kidney is associated with poor prognosis. The prognosis in fetal unilateral multicystic dysplastic kidney depends primarily on the condition of the contralateral kidney and the existence of associated anomalies.

Mortality and Medical Complications of Subtrochanteric Fracture Fixation.

: IntroductionThe aim of this study was to define the incidence and investigate the associations with mortality and medical complications, in patients presenting with subtrochanteric femoral fractures subsequently treated with an intramedullary nail, with a special reference to advancement of age. Materials and Methods: A retrospective review, covering an 8-year period, of all patients admitted to a Level 1 Trauma Centre with the diagnosis of subtrochanteric fractures was conducted. Normality was assessed for the data variables to determine the further use of parametric or non-parametric tests. Logistic regression analysis was then performed to identify the most important associations for each event. A p-value < 0.05 was considered significant. Results: A total of 519 patients were included in our study (age at time of injury: 73.26 ± 19.47 years; 318 female). The average length of hospital stay was 21.4 ± 19.45 days. Mortality was 5.4% and 17.3% for 30 days and one year, respectively. Risk factors for one-year mortality included: Low albumin on admission (Odds ratio (OR) 4.82; 95% Confidence interval (95%CI) 2.08–11.19), dementia (OR 3.99; 95%CI 2.27–7.01), presence of pneumonia during hospital stay (OR 3.18; 95%CI 1.76–5.77) and Charlson comorbidity score (CCS) > 6 (OR 2.94; 95%CI 1.62–5.35). Regarding the medical complications following the operative management of subtrochanteric fractures, the overall incidence of hospital acquired pneumonia (HAP) was 18.3%. Patients with increasing CCS (CCS 6–8: OR 1.69; 95%CI 1.00–2.84/CCS > 8: OR 2.02; 95%CI 1.03–3.95), presence of asthma/chronic obstructive pulmonary disease (COPD) (OR 2.29; 95%CI 1.37–3.82), intensive care unit (ICU)/high dependency unit (HDU) stay (OR 3.25; 95%CI 1.77–5.96) and a length of stay of more than 21 days (OR 8.82; 95%CI 1.18–65.80) were at increased risk of this outcome. The incidence of post-operative delirium was found to be 10.2%. This was associated with pre-existing dementia (OR 4.03; 95%CI 0.34–4.16), urinary tract infection (UTI) (OR 3.85; 95%CI 1.96–7.56), need for an increased level of care (OR 3.16; 95%CI 1.38–7.25), pneumonia (OR 2.29; 95%CI 1.14–4.62) and post-operative deterioration of renal function (OR 2.21; 95%CI 1.18–4.15). The incidence of venous thromboembolism (VTE) was 3.7% (pulmonary embolism (PE): 8 patients; deep venous thrombosis (DVT): 11 patients), whilst the incidence of myocardial infarction (MI)/cerebrovascular accidents (CVA) was 4.0%. No evidence of the so called “weekend effect” was identified on both morbidity and mortality. Regression analysis of these complications did not reveal any significant associations. Conclusions: Our study has opened the field for the investigation of medical complications within the subtrochanteric fracture population. Early identification of the associations of these complications could help prognostication for those who are at risk of a poor outcome. Furthermore, these could be potential “warning shots” for clinicians to act early to manage and in some cases prevent these devastating complications that could potentially lead to an increased risk of mortality.

Hemodynamically adjusted infrahepatic inferior venous cava clamping can reduce postoperative deterioration in renal function: a retrospective observational study.

Infrahepatic inferior vena cava (IIVC) clamping is beneficial for reducing the amount of bleeding during hepatic surgery, although the associated systemic circulatory deterioration is noticeable. The relationship between changes in the degree of IIVC clamping and postoperative renal function was retrospectively evaluated. A total of 59 patients who underwent elective hepatic surgery with surgical IIVC clamping in the two years were analyzed. In 2016, constant 80% clamping of the IIVC was performed (29 cases), and in 2017, hemodynamically adjusted IIVC clamping was performed (30 cases). Intraoperative parameters, including total blood loss and number of blood transfusions, were examined. The use of each vasoactive agents was analyzed. Renal function in the acute postoperative phase was evaluated using serum creatinine (Cr) and estimated glomerular filtration rate (eGFR) values. Comparison of the two groups showed that bolus doses of both ephedrine and phenylephrine were significantly higher in the 2016 group (P = 0.0221, 0.0017). Continuous doses of dopamine were significantly higher in the 2016 group, while those of noradrenaline were not. Postoperative serum Cr levels relative to baseline (%) were significantly higher in the 2016 group immediately after surgery and on postoperative day (POD) 1 (P = 0.0143, 0.0012). Postoperative eGFR relative to baseline (%) was significantly higher in the 2016 group immediately postoperatively and on PODs 1 and 2 (P = 0.0042, 0.0003, 0.0382). Hemodynamically adjustable IIVC clamping might be superior to uniformly fixed clamping in preserving renal function without compromising the desired effect on hemostasis.

Changes in separate renal function in patients who underwent minimally invasive renal stone surgery according to the preoperative functional deterioration

The significant predictors for the postoperative deterioration of separate renal function after minimally invasive stone surgery were investigated in the present prospective and observational study. A total of 117 consecutive patients who underwent retrograde intrarenal surgery or mini-percutaneous nephrolithotomy for renal calculi >10 mm were included in the present study. Perioperative changes in separate renal function were evaluated with Technetium-99m-Diethylene TriaminePenta acetic acid scan prior to intervention and at postoperative 3 months. Based on the functional differences between bilateral renal units, deterioration of separate renal function was graded into the following three groups: normal deterioration (<10%), moderate deterioration (10–20%), and severe deterioration (>20%). A total of 46 patients had a normal separate renal function, while 71 (60.7%) showed abnormal separate function in the involved side, including 29 (24.8%) moderate and 42 (35.9%) severe deterioration. Postoperatively, 48 patients (41.0%) showed aggravation or no recovery of separate renal function. Of the 46 patients with normal separate function, only 9 patients (19.5%) showed postoperative aggravation. Patients with moderate and severe deterioration showed aggravation (n = 7, 24.1%) or no recovery of separate renal function (n = 32, 76.1%, P < 0.001). Preoperative severe deterioration of separate renal function was an independent significant predictor for the postoperative deterioration of renal function (OR: 9.09, 95% CI: 4.007–20.624, P < 0.001). Lower preoperative deterioration of separate renal function showed a high probability of functional recovery. Therefore, it is hypothesized that early intervention might be necessary in cases where the patient exhibits severe aggravation of renal function.

Endovascular Repair of Thoracoabdominal and Arch Aneurysms in Patients with Connective Tissue Disease Using Branched and Fenestrated Devices

Prophylactic open surgery is the standard practice in patients with connective tissue and thoracoabdominal aortic aneurysm (TAAA) and aortic arch disease. Branched and fenestrated devices offer a less invasive alternative but there are concerns regarding the durability of the repair and the effect of the stent graft on the fragile aortic wall. The aim of this study is to evaluate mid-term outcomes of fenestrated and/or branched endografting in patients with connective tissue disease. All patients with connective tissue disease who underwent TAAA or arch aneurysm repair using a fenestrated and/or branched endograft in a single, high-volume center between 2004 and 2015 were included. Ruptured aneurysms and acute aortic dissections were excluded from this study, but not chronic aortic dissections. In total, 427 (403 pararenal and TAAAs, and 24 arch aneurysms) endovascular interventions were performed during the study period. Of these, 17 patients (4%) (16 TAAAs, 1 arch) had connective tissue disease. All patients were classified as unfit for open repair. The mean age was 51±8years. Thirteen patients with TAAA were treated with a fenestrated, 1 with a branched, and 2 with a combined fenestrated/branch device. A double inner branch device was used to treat the arch aneurysm. The technical success rate was 100% with no incidence of early mortality, spinal cord ischemia, stroke, or further dissection. Postoperative deterioration in renal function was seen in 3 patients (18.8%) and no hemodialysis was required. The mean follow-up was 3.4years (0.3-7.4). Aneurysm sac shrinkage was seen in 35% of patients (6/17) and the sac diameter remained stable in 65% of patients (11/17). No sac or sealing zone enlargement was observed in any of the patients and there were no conversions to open repair. Reintervention was required in 1 patient at 2 years for bilateral renal artery occlusion (successful fibrinolysis). One type II endoleak (lumbar) is under surveillance and 1 type III (left renal stent) sealed spontaneously. One patient died at 2years after the procedure from nonaortic causes (endocarditis). The favorable mid-term outcomes in this series that demonstrate fenestrated and/or branched endografting should be considered in patients with connective tissue and TAAA and aortic arch disease, which are considered unfit for open surgery. All patients require close lifetime surveillance at a center specializing in aortic surgery, with sufficient experience in both open and endovascular aortic surgery, so that if endovascular treatment failure occurs it can be recognized early and further treatment offered.

Geometric Alteration of Renal Arteries After Fenestrated Grafting and the Impact on Renal Function

This study aims to investigate the degree of geometric change on renal arteries and its impact on renal function after fenestrated endovascular aortic repair (fEVAR). Twenty-five patients with fEVAR were included. There were 47 renal arteries target vessels, and 43 of these (22 left and 21 right vessels) stented successfully. Their preoperative and first postoperative follow-up computed tomography (CT) images were reconstructed using the Aquarius workstation (TeraRecon, San Mateo, CA, USA). The superior mesenteric artery (SMA) or celiac axis (if SMA was stented) was appointed as reference origin. The longitudinal orientation of a renal artery or a stent was represented by a takeoff angle (ToA) between the renal artery or stent and the distal abdominal aorta. The postoperative stent ToAs were compared with those of preoperative renal arteries. Preoperative and short-term postoperative serum creatinine levels were measured. Renal function impairment was indicated as a >30% or >2.0mg/dL rise in serum creatinine compared to the preoperative level. The relationship between postoperative renal function impairment and the stent orientation or geometric changes in renal arteries was correlated. The patency rate of renal arteries was 100% at the first postoperative CT review. The average ToAs of both renal arteries were significantly enlarged after stenting (P<0.05). Seven stent deformations (16.3%) in four patients (16.0%) were observed. They were attributed to caudal misalignment of the fenestrated stent graft (n=6) or inaccurate graft sizing (n=1). There was no stent fracture or target vessel loss. Postoperatively, nine patients (36.0%) at day 1 and 10 patients (41.7%) after 3 months suffered the renal function impairment. This was found not to be associated with the stent angulation or angular change of the renal arteries (both P>0.05). The three patients with stent deformation due to misalignment suffered postoperative renal function impairment and continuing deterioration in renal function. Implanted renal stents could angulate renal arteries more cephalad after fenestrated stenting. Postoperative renal function impairment was not associated with the stent orientation and changes in vessel orientation. Accurate fenestrated alignment is important to maintain stent performance and preserve renal function.

Aortic calcification burden predicts deterioration of renal function after radical nephrectomy

BackgroundRadical nephrectomy for renal cell carcinoma (RCC) is a risk factor for the development of chronic kidney disease (CKD), and the possibility of postoperative deterioration of renal function must be considered before surgery. We investigated the contribution of the aortic calcification index (ACI) to the prediction of deterioration of renal function in patients undergoing radical nephrectomy.MethodsBetween January 1995 and December 2012, we performed 511 consecutive radical nephrectomies for patients with RCC. We retrospectively studied data from 109 patients who had regular postoperative follow-up of renal function for at least five years. The patients were divided into non-CKD and pre-CKD based on a preoperative estimated glomerular filtration rate (eGFR) of ≥60 mL/min/1.73 m2 or <60 mL/min/1.73 m2, respectively. The ACI was quantitatively measured by abdominal computed tomography before surgery. The patients in each group were stratified between low and high ACIs. Variables such as age, sex, comorbidities, and pre- and postoperative renal function were compared between patients with a low or high ACI in each group. Renal function deterioration-free interval rates were evaluated by Kaplan-Meier analysis. Factors independently associated with deterioration of renal function were determined using multivariate analysis.ResultsThe median age, preoperative eGFR, and ACI in this cohort were 65 years, 68 mL/min/1.73 m2, and 8.3%, respectively. Higher ACI (≥8.3%) was significantly associated with eGFR decline in both non-CKD and pre-CKD groups. Renal function deterioration-free interval rates were significantly lower in the ACI-high than ACI-low strata in both of the non-CKD and pre-CKD groups. Multivariate analysis showed that higher ACI was an independent risk factor for deterioration of renal function at 5 years after radical nephrectomy.ConclusionsAortic calcification burden is a potential predictor of deterioration of renal function after radical nephrectomy.Trial registrationThis study was registered as a clinical trial: UMIN000023577

Acute kidney injury after cardiovascular surgery

Acute kidney injury (AKI) is a complication experienced by many patients undergoing cardiovascular surgery. Postoperative deterioration in renal function is associated with an increased risk of in-hospital mortality and affects long-term survival. Developing strategies to identify and treat AKI is important to reduce incidence and optimize outcomes.

Quantified Aortic Luminal Irregularity as a Predictor of Complications and Prognosis After Endovascular Aneurysm Repair.

Atheromatous degeneration of the aorta is considered to be a risk factor for postoperative embolic complications after endovascular treatment, and is associated with a high incidence of vascular events in the long term. We devised a method to quantify the shagginess of the aorta using contrast-enhanced computed tomography (CT) images. This study examined the method's validity and prognostic usefulness in patients undergoing elective endovascular abdominal aortic aneurysm repair (EVAR).We retrospectively investigated 427 patients who underwent elective EVAR between 2007 and 2013. Preoperative contrast-enhanced CT images with a slice thickness of 1 mm were analyzed using a workstation, and the degree of aortic luminal irregularity from the level of the left subclavian artery ostium to that of the celiac artery ostium was quantified by computing a shagginess score. We compared the computed scores with subjective visual assessments of aortic shagginess. Subsequently, we evaluated the relationship between the computed scores and postoperative prognosis.The shagginess scores were significantly correlated with the visual assessments of the aortic lumen, which were performed by 5 experienced vascular surgeons (rho ranged from 0.564–0.654, all P < 0.001). Multiple logistic regression analysis demonstrated that the shagginess score was independently associated with the development of renal impairment within a month after EVAR (odds ratio, 2.78; 95% confidence interval [CI], 1.83–4.22, P < 0.001). The shagginess score was significantly higher in patients who suffered postoperative intestinal and peripheral ischemic complications, as compared with those who did not (P < 0.001). The mean postoperative follow-up period was 1207 ± 641 days. Cox proportional hazards regression showed that the shagginess score was a significant independent predictor of all-cause and cardiovascular mortality (hazard ratio [HR], 1.37; 95% CI, 1.09–1.72, P = 0.007, and HR, 1.51; 95% CI, 1.04–2.18, P = 0.030, respectively).The results suggest that the shagginess score provides a quantitative reflection of aortic luminal irregularity. It may serve as a useful predictive factor for postoperative renal function deterioration, embolic complications, and long-term mortality after elective EVAR.

Impact of perioperative administration of 6% hydroxyethyl starch 130/0.4 on serum cystatin C-derived renal function after radical prostatectomy: a single-centre retrospective study.

BackgroundHydroxyethyl starch (HES) is used for repletion of acute intravasal volume loss in surgical patients. However, in critically ill patients, HES is associated with acute kidney injury. We aimed to evaluate the effect of HES on perioperative cystatin C (cystC)-derived estimated glomerular filtration rates (eGFRcystC) in patients undergoing open and robot-assisted radical prostatectomy.MethodsIn this retrospective study we included 179 patients who underwent general anaesthesia for radical prostatectomy received HES perioperatively, and had complete cystC and fluid therapy data available. CystC and corresponding eGFRcystC at postoperative days 1, 3, and 5 were compared with preoperative baseline using Wilcox rank-sum test.ResultsIn 179 eligible patients, 6 % HES 130/0.4 was administered in a median (25th to 75th percentile) dose of 1000 mL (1000 to 1000 mL). Baseline eGFRcystC was 109.4 mL/min (100.3 to 118.7 mL/min). eGFRcystC on postoperative days 1, 3, and 5 was 120.4 mL/min (109.4 to 134.0 mL/min), 120.4 mL/min (109.4 to 132.9 mL/min), and 117.9 mL/min (106.6 to 129.8 mL/min), respectively (p < 0.001 compared with baseline, each). No patient had an eGFRcystC-decrease of ≥25 % from baseline.ConclusionsThe results indicate that the administration of a median dose of 1000 mL of 6 % HES 130/0.4 is not associated with a postoperative deterioration of renal function in patients with normal to near-normal baseline renal function undergoing radical prostatectomy.

Early Effects of Percutaneous Nephrolithotomy on Glomerular Filtration Rate and Determining the Potential Risk Factors Responsible for Acute Postoperative Renal Function Impairment

Background: In this study, the early effects of percutaneous nephrolithotomy (PCNL) on glomerular filtration rate (GFR) was assessed in different postoperative times and likewise, we determined the correlation of different variables with significant postoperative GFR drop after PCNL. M aterials and Methods: Patient records of 486 cases that had undergone PCNL from January 2010 to October 2011 were reviewed retrospectively. GFR in six hours, one, two and three days after PCNL and in the discharge day were calculated and then compared with preoperative level. Correlation between different variables (Perioperative hemorrhage, co-morbidities, previous stone surgery, renal anomaly, number of access, stone burden and location) and risk of acute postoperative renal function impairment (GFR drop greater than 25%) were assessed. R es ults: Mean preoperative GFR was 87.85±29.41ml/min/1.73m² which decreased to 86.18±28.77, 78.45±28.74, 78.79±26.94, 84.24±29.71 and 86.18±28.77 in 6, 24, 48 and 72 hours after surgery and discharge day post PCNL, respectively. GFR significantly decreased in one and two days after surgery (p value<0.0001 and p value <0.05) but returned to near preoperative values in 3th post PCNL day. Among different variables, only perioperative bleeding (Cut-off point for serum hemoglobin drop was 2.8 mg/dL) was concomitant with significant postoperative renal function impairment. C onclusion: Our findings revealed that co-morbidities, large or multiple stones, multiple punctures and previous history of stone surgery have no significant impact on surgical outcomes. Postoperative GFR returned to near preoperative values in a few days after operation. Avoidance of significant perioperative bleeding is an important point to prevent post PCNL renal insufficiency.

634 RISK FACTORS OF RENAL FUNCTION DETERIORATION AFTER (PARTIAL) TUMOR NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Evaluation & Staging (I)1 Apr 2013634 RISK FACTORS OF RENAL FUNCTION DETERIORATION AFTER (PARTIAL) TUMOR NEPHRECTOMY Brigitte Schwaiger, Marianne Schmid, Werner Tenschert, Marc Shaffu, Rana Thabaz, Jessica Langetepe, Christian Eichelberg, Sascha Ahyai, Margit Fisch, and Felix KH Chun Brigitte SchwaigerBrigitte Schwaiger Hamburg, Germany More articles by this author , Marianne SchmidMarianne Schmid Hamburg, Germany More articles by this author , Werner TenschertWerner Tenschert Hamburg, Germany More articles by this author , Marc ShaffuMarc Shaffu Hamburg, Germany More articles by this author , Rana ThabazRana Thabaz Hamburg, Germany More articles by this author , Jessica LangetepeJessica Langetepe Hamburg, Germany More articles by this author , Christian EichelbergChristian Eichelberg Hamburg, Germany More articles by this author , Sascha AhyaiSascha Ahyai Hamburg, Germany More articles by this author , Margit FischMargit Fisch Hamburg, Germany More articles by this author , and Felix KH ChunFelix KH Chun Hamburg, Germany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.186AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A reduction of renal mass due to partial (PN) or radical tumor nephrectomy (RN) is followed by substantial loss of renal function (RF). Within the course of follow-up (FU), these patients are at further risk for renal function deterioration and ultimately development of chronic kidney disease (CKD). This investigation aimed to identify risk factors for postoperative renal function deterioration in renal cell carcinoma (RCC) patients with a preoperative GFR > 60 ml/min/1.73m2. METHODS Since January 2011, renal functional data of 31 RCC patients undergoing PN or RN were prospectively investigated. Data consisted of serum creatinine (SCr), glomerular filtration rate (eGFR), serum Cystatin C (SCysC) and SCysC-based GFR (cGFR), clinical characteristics including body mass index (BMI), blood pressure, proteinuria, history of diabetes, blood lipid levels. Using univariable Cox regression analyses, these pre-op parameters were used to identify patients with a) an eGFR< 60 and b) the presence of a new onset arterial hypertonia (aHT). These endpoints served as proxies of FU renal function 1 year after surgery. RESULTS The cohort consisted of 20 (65%) men and 11 (35%) women aged 58 years (range 42 - 72). Mean follow-up (FU) was 13.4 months after PN (52%) or RN (48%). Preoperative baseline eGFR and cGFR was 85.9 and 109.6, respectively. Renal function risk factors, such as BMI > 30, aHT and proteinuria were present preoperatively in 16, 42 and 29%, respectively. At 1 year FU, BMI > 30, proteinuria, HbA1c levels > 6% and hypercholesterolemia was present in 32, 29, 35 and 65%, respectively, and 31% presented a new onset aHT. Expectedly, at 1 year post-OP FU, eGFR vs. cGFR significantly decreased (-15.5 vs. -19.8; p<0.001) compared to pre-OP measurements. Further, 71% demonstrated an eGFR < 60. In univariable analyses, significant risk factors for a) an eGFR < 60 at FU were a pathologically elevated SCr the first postoperative day (p=0.018, OR=8,64) and the surgical procedure (PN vs. RN, p=0.054, OR=0.22) and b) new onset aHT was the age at operation (p=0.031, OR=1.25). A SCysC elevation over normal range the first day following RN/PN was not significantly associated to the chosen outcomes. CONCLUSIONS Patients undergoing (partial) tumor nephrectomy demonstrate severe RF deterioration in the 1-year FU. Early management of pre-existing risk factors such as type of surgery and early change in SCr, as well as aHT and control of body weight are essential for postoperative RF outcome. Since in the 1 year FU, RF is still decreasing attentive after-care to avoid further renal function deterioration is warranted. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e259 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brigitte Schwaiger Hamburg, Germany More articles by this author Marianne Schmid Hamburg, Germany More articles by this author Werner Tenschert Hamburg, Germany More articles by this author Marc Shaffu Hamburg, Germany More articles by this author Rana Thabaz Hamburg, Germany More articles by this author Jessica Langetepe Hamburg, Germany More articles by this author Christian Eichelberg Hamburg, Germany More articles by this author Sascha Ahyai Hamburg, Germany More articles by this author Margit Fisch Hamburg, Germany More articles by this author Felix KH Chun Hamburg, Germany More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

The Effect of Mild Preoperative Renal Impairment on Early Postoperative Mortality after Open Cardiac Surgery

Introduction: Severe preoperative renal impairment (RI) is often included in score systems used to predict outcome after open cardiac surgery. The purpose of this study was to investigate the impact of mild preoperative RI on the early postoperative mortality after open heart surgery. Methods: We retrospectively collected data of all patients who underwent open cardiac surgery in Kuwait Chest Disease Hospital from January 2005 to June 2006. Multiple baseline and perioperative variables, including the presence of mild preoperative RI, were scrutinized for potential association with early post operative mortality. Results: The study included 500 subjects, 47 of whom had mild preoperative RI, defined by an estimated glomerular filtration rate (eGFR) between 89-60 ml/min. The overall 30 days mortality was 6.8%. Mortality was 40.8% in patients who had mild preoperative RI, 28.7% in patients who developed acute postoperative deterioration in renal function and 33.3% in patients who required dialysis postoperatively. Binary logistic regression analysis showed that the development of postoperative multi-organ failure (MOF), female gender and mild preoperative RI were the only independent variables predicting early post operative mortality after cardiac surgeries. Conclusion: A number of studies have identified moderate to severe RI as a predictor of mortality and morbidity after open heart surgery. RI is often associated with other comorbidities which are likely to have a negative impact on morbidity and mortality after open heart surgery. However, in this study mild preoperative RI remained a strong predictor of early mortality even after adjustment for several confounders. Keywords: cardiac surgery, chronic kidney disease, renal impairment, mortality