Postoperative Serum Creatinine Levels Research Articles

Oncological and functional outcomes of salvage renal surgery following failed primary intervention for renal cell carcinoma.

Purpose To assess the oncologic and functional outcomes of salvage renal surgery following failed primary intervention for RCC.Materials and Methods We performed a retrospective review of patients who underwent surgery for suspected RCC during 2004-2012. We identified 839 patients, 13 of whom required salvage renal surgery. Demographic data was collected for all patients. Intraoperative and postoperative data included ischemic duration, blood loss and perioperative complications. Preoperative and postoperative assessments included abdominal CT or magnetic resonance imaging, chest CT and routine laboratory work. Estimated glomerular filtration rate (eGFR) was calculated according to the Modification of Diet in Renal Disease equation.Results The majority (85%) of the patients were male, with an average age of 64 years. Ten patients underwent salvage partial nephrectomy while 3 underwent salvage radical nephrectomy. Cryotherapy was the predominant primary failed treatment modality, with 31% of patients undergoing primary open surgery. Pre-operatively, three patients were projected to require permanent post-operative dialysis. In the remaining 10 patients, mean pre- and postoperative serum creatinine and eGFR levels were 1.35 mg/dL and 53.8 mL/min/1.73 m2 compared to 1.43 mg/dL and 46.6 mL/min/1.73 m2, respectively. Mean warm ischemia time in 10 patients was 17.4 min and for all patients, the mean blood loss was 647 mL. The predominant pathological stage was pT1a (8/13; 62%). Negative surgical margins were achieved in all cases. The mean follow-up was 32.9 months (3.5-88 months).Conclusion While salvage renal surgery can be challenging, it is feasible and has adequate surgical, functional and oncological outcomes.

Acute kidney injury after coronary artery bypass grafting and long-term risk of end-stage renal disease.

Acute kidney injury (AKI) is a common complication after coronary artery bypass grafting (CABG) and is associated with adverse outcomes. However, the relationship between AKI after CABG and the long-term risk of end-stage renal disease (ESRD) is unknown. This study included 29 330 patients who underwent primary isolated CABG in Sweden between 2000 and 2008. AKI was classified according to the Acute Kidney Injury Network (AKIN) classification: stage 1, >0.3 mg/dL (>26 μmol/L) or 50% to 100% increase; stage 2, 100% to 200% increase; and stage 3, >200% increase from the preoperative to postoperative serum creatinine level. Cox proportional hazards regression analysis was used to calculate hazard ratios with 95% confidence intervals for ESRD in AKIN stage 1 and stage 2 to 3. Postoperative AKI occurred in 13% of patients. During a mean follow-up of 4.3±2.4 years, 123 patients (0.4%) developed ESRD, including 50 (1.6%) in AKIN stage 1, 29 (5.2%) in AKIN stage 2 to 3, and 44 (0.2%) without AKI after CABG. After multivariable adjustment, the hazard ratio for ESRD was 2.92 (95% confidence interval, 1.87-4.55) for AKIN stage 1 and 3.81 (95% confidence interval, 2.14-6.79) for AKIN stage 2 to 3. This nationwide study of patients who underwent CABG found that a small increase in the postoperative serum creatinine level was associated with an almost 3-fold increase in the long-term risk of ESRD after adjustment for a number of confounders, including preoperative renal function.

Remote ischemic preconditioning is a safe adjuvant technique to myocardial protection but adds no clinical benefit after on-pump coronary artery bypass grafting.

To evaluate the impact of remote ischemic preconditioning (RIPC) on clinical outcome, biological markers of myocardial injury, and its safety in patients undergoing on-pump coronary artery bypass grafting (CABG). This study was conducted at Ch. Pervaiz Elahi Institute of Cardiology (CPEIC) in Multan. The study took place from March 2012 to June 2013. Patients were randomly placed into two groups. Group A (N = 32) did not undergo RIPC; Group B (N = 35) received RIPC after induction of anesthesia. Similar standard general anesthesia, cardiopulmonary technique, myocardial protection strategies, and surgical techniques were used in both groups except the protocol for RIPC. Following postoperative outcome, i.e. cardiac defibrillation after removal of aortic cross clamp during the period of rewarming, demand for intra-aortic balloon pump (IABP), demand for antiarrhythmic before leaving the operation room, postoperative creatine kinase-myocardial band (CK-MB) level (at 1h, 12h, 24h, and 48h after surgery), postoperative serum creatinine level on first postoperative day, postoperative ejection fraction (EF) on third postoperative day, in-hospital mortality, and one-year mortality were noted, prospectively. Safety of protocol of RIPC was estimated by limb ischemia monitored by pulse oximetry during and after procedure of RIPC and postoperative neurapraxia by nerve examination of right upper limb. Post aortic cross clamp release cardiac defibrillation, demand for IABP, demand for high inotropes, and use of antiarrhythmic in the operation room were statistically insignificant in the non-RIPC and RIPC group with P values of .54, .78, .16, and .16, respectively. Mean postoperative CK-MB level (IU/L) showed the following results: At 1h (Group A 20.94 + 1.66, Group B 20.57 + 1.54, P = .35), at 12h (Group A 27.13 + 1.85, Group B 28.05 + 3.04, P = .135), at 24h (Group A 27.63 + 1.7, Group B 27.85 + 2.2, P = .63), and at 48h (Group A 22.95 + 2.76, Group B 23.27 + 3.6, P = .69). First postoperative day serum creatinine (Group A 1.29 + 0.395, Group B 1.33 + 0.57, P = .77) and postoperative ejection fraction percentage on the third postoperative day (Group A 50.78 + 8.72, Group B 50.57 + 8.38, P = .92) showed no statistical difference between two groups. Postoperative low cardiac output state, in-hospital mortality, and one-year mortality also were statistically insignificant between the groups with P values of .93, .29, and .33, respectively. None of the patients in either group showed evidence of limb ischemia and neurapraxia of the right upper limb. RIPC is a safe technique, but it does not have additional clinical benefit after on-pump CABG surgery in the presence of a standard myocardial protective strategy.

Volatile anesthetics in preventing acute kidney injury after cardiac surgery: A systematic review and meta-analysis

Acute kidney injury is a common clinical complication of cardiac surgery. Volatile anesthetics have been shown to protect against it in animal experiments. Clinically, however, the effect of volatile anesthetics has been unclear. We conducted a systematic review and meta-analysis of randomized, controlled trials to explore whether volatile anesthetics could provide renal protection to patients undergoing cardiac surgery. Randomized, controlled trials were identified in PubMed, Ovid, Excerpta Medica Database, Cochrane Library, Current Controlled Trials Register, reviews, and reference lists of relevant articles. Ten trials with 1600 total participants were eligible. Data were analyzed with both fixed- and random-effects models. Relative to control data, volatile anesthetics significantly reduced acute kidney injury incidence (relative risk [RR], 0.65; 95% confidence interval [CI], 0.43-0.97; P = .04). Although there was no significant difference between groups in absolute postoperative serum creatinine level and mortality, patients receiving volatile anesthetics had significantly (or borderline) lower increase in serum creatinine level from baseline on the first (weighted mean difference, -0.04 mg/dL; 95% CI, -0.07 to -0.01 mg/dL; P = .002) and second (weighted mean difference, -0.07 mg/dL, 95% CI, -0.14 to -0.00 mg/dL; P = .05) postoperative days and reduced incidences of prolonged intensive care unit stay (RR, 0.46; 95% CI, 0.34-0.64; P < .001) and hospitalization (RR, 0.47; 95% CI, 0.27-0.83; P = .009). Current evidence shows that volatile anesthetics may provide renal protection in patients undergoing cardiac surgery and supports further randomized, controlled trials with larger sample sizes and high methodologic quality.

Hypertension and Hepatitis C Virus Infection Are Strong Risk Factors for Developing Late Renal Dysfunction After Living Donor Liver Transplantation: Significance of Renal Biopsy

BackgroundLate renal dysfunction (LRD) after liver transplantation develops due to several factors such as viral hepatitis, calcineurin inhibitor, diabetes mellitus, and hypertension. The aim of our study was to clarify the risk factors for LRD after living donor liver plantation (LDLT) by using simple criteria for LRD and paying special attention to the significance of renal biopsy. Patients and MethodsAmong the 98 recipients undergoing LDLT between March 2002 and June 2008, there were 77 patients who survived more than 1 year and had been followed at our clinic. LRD was simply defined as a postoperative serum creatinine level of 1.5/L or more at any point in time after 1 year from undergoing LDLT. The perioperative risk factors for developing LRD after LDLT were analyzed by uni- and multivariate analyses, and regardless of serum creatinine level, a renal biopsy was indicated when the patient developed clinical symptoms. ResultsComparing the risk factors between 22 patients with LRD and 55 without LRD, univariate analysis revealed recipient's age, generation, hypertension, hepatitis C virus (HCV) antibody−positive, pretransplantation serum creatinine level, and graft-to-recipient weight ratio to be significant risk factors. By multivariate analysis, HCV and hypertension were selected as independent risk factors. Renal biopsy was indicated in the 4 patients with proteinuria, all of whom were positive for HCV. However, by histologic and/or electron micrographic analyses, only 1 patient was diagnosed with HCV-related membranous proliferative nephritis, 1 with diabetic nephropathy, and 2 with drug (tacrolimus) −induced renal dysfunction. ConclusionAlthough HCV and hypertension were determined to be independent risk factors for LRD after LDLT, a renal biopsy should be performed when clinical symptoms develop regardless of creatinine levels to provide appropriate treatment.

Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions

Aortic sources of peripheral and visceral embolization remain challenging to treat. The safety of stent graft coverage continues to be debated. This study reports the outcomes of stent coverage of these complex lesions. Hospital records were retrospectively reviewed for patients undergoing aortic stenting between 2006 and 2013 for visceral and peripheral embolic disease. Renal function, method of coverage, and mortality after stent grafting were reviewed. Twenty-five cases of embolizing aortic lesions treated with an endovascular approach were identified. The mean age was 65 ± 13 years (range, 45-87 years), and 64% were female. Sixteen (64%) patients presented with peripheral embolic events, six with concomitant renal embolization. Five patients presented with abdominal or flank pain, and two were discovered incidentally. Three patients had undergone an endovascular procedure for other indications within the preceding 6 months of presentation. Nineteen patients had existing chronic kidney disease (stage II or higher), but only three had stage IV disease. Of the eight patients tested, four had a diagnosed hypercoagulable state. Eight of the patients had lesions identified in multiple aortic segments, and aortic aneurysm disease was present in 24%. Coverage of both abdominal and thoracic sources occurred in eight patients, whereas 17 had only one segment covered. Minimal intraluminal catheter and wire manipulation was paired with the use of intravascular ultrasound in an effort to reduce embolization and contrast use. Intravascular ultrasound was used in the majority of cases and transesophageal echo in 28% of patients. Two patients with stage IV kidney disease became dialysis-dependent within 3 months of the procedure. No other patients had an increase in their postoperative or predischarge serum creatinine levels. No embolic events were precipitated during the procedure, nor were there any recurrent embolic events detected on follow-up. The 1-year mortality rate was 25%. Endovascular coverage of atheroembolic sources in the aorta is feasible and is safe and effective in properly selected patients. It does not appear to worsen renal function when performed with the use of specific technical strategies.

Comparison of Contrast-Enhanced Ultrasound Scan (CEUS) and MRI in the follow-up of cryoablation for small renal tumors. Experience on 25 cases

Percutaneous ablation in the kidney is now performed as a standard therapeutic nephron-sparing option in patients who are poor candidates for resection. Its increasing use has been largely prompted by the rising incidental detection of renal cell carcinomas with cross-sectional imaging and the need to preserve renal function in patients with comorbid conditions, multiple renal cell carcinomas, and/or heritable renal cancer syndromes. To date, clinical studies indicate that cryoablation is an effective therapy with acceptable short- to intermediate-term outcomes and with a low risk in the appropriate setting. This article focuses on the efficiency of contrast enhanced ultrasound scan (CEUS) as compared to contrast enhanced magnetic resonance imaging (MRI) during the follow-up after cryoablation of small renal tumors. In our Department, percutaneous or laparoscopic assisted cryoablation is offered in the treatment of small renal masses. Between January 2009 and January 2013, 25 patients (pts) were treated with laparoscopic assisted cryoablation or percutaneous cryoablation for renal tumors <3.5 cm in pts unfit for surgery. All pts had severe comorbidities (ASA score 3). Transperitoneal laparoscopic approach was performed in 11 pts, extraperitoneal approach in 3 pts, percutaneous technique was performed in 11 patients. "Tru-cut biopsy" of the renal mass was always performed before cryoablation. The SeedNet system (Galil Medical, Arden Hills, MN) was used in 12/25 pts; the Precise system (Galil Medical, Arden Hills, MN) was used in 13/25 pts. In all cases, IceRod needles were used. Real-time ultrasound guidance was used to localize the tumour and to monitor the progression of "iceball". A double "freeze-thaw cycle" was used. All pts had MRI and CEUS before cryoablation and the follow-up consisted in CEUS/MRI every 3 months during the first year and every 6 months thereafter. The mean age of the 25 pts was 67.7 years (range 56-79); 5 pts were females and 20 were males. The mean tumor size was 2.8 cm (range 1.5-3.5). No patient required conversion to open procedure. 19 tumors were located at the lower pole, 4 were interpolar and 2 tumors were located at the upper pole. There were no intraoperative complications. The mean hospital stay was 4 days (range 1-7). Two pts required a blood transfusion; there was no statistically significant difference between preoperative and postoperative serum creatinine levels. The biopsy showed RCC in all cases. In 24/25 patients both CEUS and MRI showed no enhancement. In 1/25 pts, during the follow-up, CEUS and MRI showed a well visible recurrence at the perfusion study. It was histologically confirmed. The final results of CEUS and MRI were concordant in all pts. CEUS is effective during the follow-up of renal tumor cryoablation. It could be an alternative technique to standard CT and MRI, with some advantages: low cost, short time consuming procedure, no radiation exposure, reduced amount of contrast agent (1-2 mL) and rare adverse reactions.

Endovascular management of transplant renal artery stenosis

Most clinicians regard angioplasty with or without stent placement to be the treatment of choice for transplant renal artery stenosis (TRAS). However, published results regarding its effectiveness are heterogeneous. The aim of this study was to assess the safety and efficiency of TRAS endovascular therapy. All cases of TRAS admitted for treatment in our unit from January 2009 to December 2012 were reviewed retrospectively. The primary end point was the stenosis-free primary transplant renal artery patency. Secondary end points were freedom from reintervention, graft survival, postoperative serum creatinine level, blood pressure evolution, and the number of antihypertensive drugs pre- and postprocedure. A total of 17 patients (10 men, 7 women) presenting with TRAS were referred to our institution. During the early post-transplantation process (<15 days), 35.2% of patients presented. The median time to presentation was 40 days. The predominant presentation was graft function alteration (82.3%). Percutaneous balloon angioplasty was performed in five patients (29.4%), while stenting was performed in the remaining 12 patients (70.6%). The stenosis-free primary patency rate and freedom from reintervention rate were 76.5% and 88.2%, respectively. The median follow-up was 19.6 months with 88.2% graft survival. There were no mortalities throughout the follow-up period. Serum creatinine levels decreased significantly from 186 μmol/L (range, 148-310 μmol/L) preoperatively to 160 μmol/L (range, 127-236 μmol/L at discharge (P = .0036). The glomerular filtration rates increased from 32.1 mL/min (range, 21.4-45.8 mL/min) to 41.7 mL/min (range, 27.5-52.4 mL/min; P = .004). Systolic and diastolic blood pressure varied from 140 mm Hg (range, 137-157 mm Hg) and 75 mm Hg (range, 70-80 mm Hg), to 135 mm Hg (range, 130-147 mm Hg and 80 mm Hg (range, 73-80 mm Hg), respectively (P = .11 and P = .36). The preoperative number of antihypertensive medications was 2 (range, 1-3) and remained unchanged (P = .33). The endovascular management of TRAS is safe and presents a high rate of technical success with low morbidity. Its impact on serum creatinine levels is significant in our experience. However, the blood pressure items do not seem to improve postoperatively.

Renal function changes and seasonal temperature in patients undergoing cardiac surgery

Some observations in humans and other mammalians suggest that serum creatinine (SC) and estimated glomerular filtration rate (eGFR) may change during the warm season. The objective of this study is to determine if temperature-dependent seasonal changes in levels of SC and eGFR are detectable in cardiac surgery patients, with associated changes in postoperative acute kidney injury (AKI) incidence. This is a single-center retrospective study based on the institutional database of cardiac surgery in the period 2000–2012. Sixteen-thousand and twenty-three consecutive adult patients undergoing cardiac surgery comprised the study population. Baseline and postoperative SC and eGFR values, and AKI rate according to the month when surgery was performed were measured. The month-related changes SC and eGFR, and AKI rate, were assessed in crude and adjusted models, and their association with the correspondent meteorological data registered at the time of surgery was tested. Patients operated in the six warmest months (May through October) had a significant (p < 0.001) higher value of baseline SC (1.17 ± 0.7 mg/dL) versus the six coldest months (1.12 ± 0.6 mg/dL), and a significantly (p = 0.031) higher value of peak postoperative SC (1.31 ± 0.85 mg/dL) versus the 6 coldest months (1.28 ± 0.89), with maximum values between July and August. A similar behaviour was found for eGFR. After adjustment for other confounders, the AKI rate was not significantly different in the warmest months, even if a trend towards a higher rate in August was observed (odds ratio 1.287, 95% confidence interval 0.96–1.74, p = 0.097). Baseline (p < 0.001) and peak postoperative (p = 0.0054) serum creatinine levels were significantly higher for increasing mean ambient temperature. Humidity and wind speed were negatively associated with pre- and postoperative eGFR. In conclusion, patients operated during the warmest season, have higher levels of SC and lower levels of eGFR, without a correspondent increase in the AKI rate. Different hypotheses underlying this pattern are generated by this study, including a dehydration status, concomitant anemia, and a higher transfusion rate.

Minimal Changes in Postoperative Creatinine Values and Early and Late Mortality and Cardiovascular Events After Coronary Artery Bypass Grafting

Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with adverse outcomes. This study investigated if already a minimal change of 0 to 0.3 mg/dl in postoperative serum creatinine values was associated with early death and long-term cardiovascular outcomes and death. From the SWEDEHEART registry, we included 25,686 patients who underwent elective, isolated, primary CABG in Sweden from 2000 to 2008. AKI was categorized according to increases in postoperative creatinine values: group 1, 0 to 0.3 mg/dl; group 2, 0.3 to 0.5 mg/dl; and group 3, >0.5 mg/dl. The primary outcome measure was death from any cause. During a mean follow-up of 6 years, there were 4,350 deaths (17%) and 7,095 hospitalizations (28%) for myocardial infarction, stroke, heart failure, or death (secondary outcome). The adjusted odds ratios (95% confidence interval [CI]) for early mortality in AKI groups 1 to 3 were 1.37 (0.84 to 2.21), 3.64 (2.07 to 6.38), and 15.4 (9.98 to 23.9), respectively. For long-term mortality, the corresponding hazard ratios (95% CI) were 1.07 (1.00 to 1.15), 1.33 (1.19 to 1.48), and 2.11 (1.92 to 2.32), respectively. There was a significant association between each AKI group and the composite outcome (HR 1.09, 95% CI 1.03 to 1.15; HR 1.39, 95% CI 1.27 to 1.52; and HR 1.99, 95% CI 1.84 to 2.16, respectively). In conclusion, already a minimal increase in the postoperative serum creatinine level after CABG was independently associated with long-term all-cause mortality and cardiovascular outcomes, regardless of preoperative renal function.

The Impact of Post-transplant Hemoglobin Level on Renal Allograft Outcome

BackgroundAnemia is a common complication of chronic renal disease and renal transplantation. Early post-transplant anemia is the consequence of blood loss, immunosuppressant therapy, and failure to produce sufficient erythropoietin. Late post-transplant anemia has been attributed to drug therapy, renal dysfunction, and infection. The effect of post-transplant anemia on renal allograft survival and acute rejection rates is not established. The aim of this study was to examine the impact of post-transplant anemia on renal function and allograft outcomes. Materials and methodsWe included 411 patients who underwent living or deceased donor renal transplantations in our center from April 1990 to March 2010. The patients were divided into 2 groups according to their postoperative hemoglobin level at 1 month: anemic group (<12.0 g/dL in men, <11.0 g/dL in women) and nonanemic group (≥12.0 g/dL in men, ≥11.0 g/dL in wemen). The outcome measures included postoperative serum creatinine levels at 12 and 36 months, acute and chronic rejection rates, as well as long-term graft survival. ResultsThe acute and chronic rejection rates were significantly higher in the anemic group: 28.1% versus 19.7% (P = .000) and 24.1% versus 19.7% (P = .027), respectively. Postoperative serum creatinine levels at 12 and 36 months were not significantly different in patients with functioning grafts regardless of their anemia status (P = .530 and P = .430, respectively). Graft survival was lower with anemia: 85.4% versus 93.8% at 5 years, and 74.8% versus 83.5% at 10 years (P = .040). ConclusionsPost-transplant anemia was associated with poorer renal function at 12 months, higher acute rejection rates, and worse long-term renal allograft outcomes compared with subjects displaying normal hemoglobin levels.

Open Donor Nephrectomy is a Safe Approach for Starting Kidney Transplantation

Aim: Living kidney donation is important due to the shortage of organ donors in Turkey. Classic retroperitoneal open donor nephrectomy is more beneficial as it can prevent intraperitoneal organ injuries and postoperative adhesion formation. Here we have presented our initial experience about donors who were undergone open donor nephrectomy. Material and Methods: We retrospectively analyzed 14 donors who were undergone open nephrectomy between November 2010 and June 2011. We reviewed demographic data, intraoperative and postoperative complications, hospital stay, and serum creatinine levels (discharge time, postoperative maximum level and currently) for these donors. Results: Fourteen donors were operated during this period. The male to female ratio was 8:6 among donors. Mean age was 43.57 (range; 27-68) years. Mean body mass index was 27.71 (range; 21.3-36.1). Five right and nine left kidneys were harvested. There was no intraperitoneal organ injury. All kidney grafts started to function immediately. There was no vascular thrombosis in the transplanted kidneys. There was one major hemorrhagic complication requiring reoperation (7.1%). There were three minor wounds complications (21.4%). None of the donors had incisional hernia. Mean postoperative hospitalization time was 5.85 (range; 4-18) days. Mean flow up period was 125 days (range; 18-210 days). Mean serum creatinine level of discharge time, postoperative maximum level, and currently were; 1.04 mg/dL (range; 0.6-1.7); 1.26 mg/dL (range; 0.8-1.9); 1.08 mg/dL (range; 0.78-1.41) respectively. Conclusions; We did not have any major complication in our initial series for open donor nephrectomy. For those who are starting kidney transplantation, open donor nephrectomy is a safe method. Key words: Nephrectomy; Kidney Transplantation; Living Donor.

Association of ethnicity and acute kidney injury after cardiac surgery in a South East Asian population

Postoperative acute kidney injury (AKI) is a frequent and serious complication after cardiac surgery. Clinical factors alone have failed to accurately predict the incidence of AKI after cardiac surgery. Ethnicity has been shown to be a predictor of AKI in the Western population. We tested the hypothesis that ethnicity is an independent predictor of AKI in patients undergoing cardiac surgery in a South East Asian population. A total of 1756 consecutive patients undergoing cardiac surgery were prospectively recruited. Among them, data of 1639 patients met the criteria for analysis. There were 1182 Chinese, 195 Indian, and 262 Malay patients. The main outcome was postoperative AKI, defined as a 25% or greater increase in preoperative to a maximum postoperative serum creatinine level within 3 days after surgery. Five hundred and seventy-nine patients (35.3%) developed AKI after cardiac surgery. Ethnicity was shown to be an independent predictor of AKI after cardiac surgery with Indians and Malays having a higher risk of developing AKI when compared with Chinese patients (odds ratio: Indian vs Chinese 1.44, Malay vs Chinese 1.51). Indians and Malays have a higher risk of developing AKI after cardiac surgery than Chinese in a South East Asian population. Ethnicity was shown to be an independent predictor of AKI after cardiac surgery.

Relation of Resistive and Pulsatility Indices With Graft Function After Renal Transplant

There are conflicting data regarding the use of some measured indices by Doppler ultrasound such as the resistive index and the pulsatility index in predicting renal allograft dysfunction. This study sought to evaluate the association of early postoperative Doppler indices and 3-month serum creatinine levels in renal transplant recipients. During a 1-year period, all patients who underwent renal transplant at our hospital were recruited into a prospective study. Doppler ultrasound was performed on all patients 6 days and 3 months after the transplant and the resistive index and the pulsatility index were calculated for each patient. Then, the association between these indices and 3-month outcomes of patients were investigated. Thirty-eight patients including 21 men (mean age, 36.6 ± 13.1 y) were evaluated. There was a positive correlation between the resistive index and the pulsatility index at 6 days after transplant and the serum creatinine measured at the same day (P < .001 and r=0.570 for resistive index; P < .001 and r=0.547 for pulsatility index). There was also a positive correlation between the pulsatility index and the resistive index at 6 days after transplant and 3-month serum creatinine level (P = .009 and r=0.420 for resistive index; P = .009 and r=0.417 for pulsatility index). There were negative correlations between the resistive index and the pulsatility index on the sixth day after surgery and creatinine clearance measured at 6 days and 3 months after transplant. This study reveals a strong-to-medium correlation between the resistive index and the pulsatility index, serum creatinine level, measured 6 days after transplant.

A Double-Blind Randomized Controlled Trial of Continuous Intravenous Ketorolac vs Placebo for Adjuvant Pain Control After Renal Surgery

ObjectiveTo evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control. Patients and MethodsA prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level. ResultsThe study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13). ConclusionAlthough continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control. Trial Registrationclinicaltrials.gov Identifiers: NCT00765128 and NCT00765232

Outcomes after laparoscopic living donor nephrectomy: comparison of two laparoscopic surgeons with different levels of expertise

To test the effect of surgeon experience on donor and recipient outcomes after laparoscopic living donor nephrectomy (LLDN). Results of a LLDN expert were compared with those of an LLDN novice. Between October 2008 and October 2010 the last 20 cases of a series of 130 consecutive LLDNs, performed by an expert (EXP) were compared with the first 20 cases of an LLDN novice (NOV). Donor and recipient outcomes were evaluated. The novice was mentored by the expert during his initial four LLDN cases. Donor and recipient demographics were not different between the two surgeon groups. Total operating time and warm ischaemia time during LLDN was significantly longer in the NOV group compared with the EXP group (273 min vs 147 min and 213 s vs 162 s, respectively). The incidence of donor complications was low in both groups. Length of hospital stay among donors did not differ between groups. Although delayed graft function, rejection rates and postoperative serum creatinine levels indicated slightly poorer recipient outcomes in the NOV group, differences did not reach statistical significance. Mentoring by an experienced urological laparoscopist may help an LLDN novice to generate acceptable donor and recipient outcomes. Whether or not prolonged operating times and warm ischaemia times during the early phase of an LLDN experience are risk factors for impaired graft function needs further evaluation.

Predictive Factors for Mortality and Morbidity of Ruptured Abdominal Aortic Aneurysm Repair

Purpose: This study aimed to determine the morbidity and mortality of infrarenal ruptured abdominal aortic aneurysm (rAAA) repair, and to investigate the changes in perioperative laboratory values, as well as clarify the specific independent predictive factors for mortality and morbidity. We retrospectively evaluated patients who were treated in Jichi Medical University Hospital. Methods: A consecutive fifty-six patients with rAAA between April 2007 and August 2010 were studied. The possible predictive values of various patient-related variables on outcomes (mortality, major morbidity and renal insufficiency) were assessed by univariate and multivariate analysis. Results: The overall in-hospital mortality was 16.1%. In univariate logistic analyses, lactate dehydrogenase, alanine aminotransferase, as well as pre-operative and post-operative serum creatinine levels were significantly related to mortality. Blood transfusion volume, white blood cells and C-reactive protein levels were significantly related to major morbidity. Intraoperative blood loss, white blood cells, C-reactive protein levels, lactate dehydrogenase and pre-operative serum creatinine levels were significantly related to renal insufficiency. Conclusions: Emergency open repair can be safely performed in patients for infrarenal rAAA. In particular, we identified specific independent predictive factors of clinical examination and laboratory studies for mortality, major morbidity and renal insufficiency.

Indication to Open Anatrophic Nephrolithotomy in the Twenty-First Century: A Case Report

Introduction. Advances in endourology have greatly reduced indications to open surgery in the treatment of staghorn kidney stones. Nevertheless in our experience, open surgery still represents the treatment of choice in rare cases. Case Report. A 71-year-old morbidly obese female patient complaining about occasional left flank pain, and recurrent cystitis for many years, presented bilateral staghorn kidney stones. Comorbidities were obesity (BMI 36.2), hypertension, type II diabetes, and chronic obstructive pulmunary disease (COPD) hyperlipidemia. Due to these comorbidities, endoscopic and laparoscopic approaches were not indicated. We offered the patient staged open anatrophic nephrolithotomy. Results. Operative time was 180 minutes. Blood loss was 500 cc. requiring one unit of packed red blood cells. Hospital stay was 7 days. The renal function was unaffected based on preoperative and postoperative serum creatinine levels. Stone-free status of the left kidney was confirmed after surgery with CT scan. Conclusions. Open surgery can represent a valid alterative in the treatment of staghorn kidney stones of very selected cases. A discussion of the current indications in the twenty-first century is presented.

Subclinical changes in serum creatinine and mortality after coronary artery bypass grafting

Changes in postoperative serum creatinine levels have been used to define acute renal injury in patients undergoing cardiac surgery with cardiopulmonary bypass. It remains unclear, however, whether subclinical increases in serum creatinine that do not meet current Acute Kidney Injury Network or RIFLE (risk, injury, failure, loss, and end-stage kidney disease) criteria for acute renal injury are predictive of mortality after cardiac surgery. Multivariate logistic regression was performed in a retrospective cohort of 3914 consecutive patients undergoing primary, isolated coronary artery bypass grafting with cardiopulmonary bypass to determine whether postoperative serum creatinine change independently predicts 30-day all-cause mortality in patients with normal renal function and with varying levels of preoperative renal insufficiency. To control further for selection bias, multivariate logistic regression was performed on a propensity-matched cohort (n=2042) to determine whether subclinical increases in serum creatinine predict mortality. Negative change in serum creatinine was associated with reduced 30-day all-cause mortality. Even subclinical increases in serum creatinine were associated with increased mortality relative to patients with negative changes in serum creatinine (odds ratio, 3.93; 95% confidence interval, 1.68-9.22; P<.01). After propensity matching, subclinical increases in serum creatinine were still associated with increased mortality (odds ratio, 4.13; 95% confidence interval, 1.37-12.45; P=.01). Subclinical increases in serum creatinine that do not meet acute renal injury criteria are independently associated with 30-day all-cause mortality in patients with normal renal function or preoperative renal insufficiency undergoing coronary artery bypass grafting.

Silent Ureteral Stones: Impact on Kidney Function—Can Treatment of Silent Ureteral Stones Preserve Kidney Function?

To report our experience with silent ureteral stones and expose their true influence on renal function. We analyzed 506 patients who had undergone ureterolithotripsy from January 2005 to May 2010. Silent ureteral stones were calculi found in the absence of any specific or subjective ureteral stone-related symptoms. Of the 506 patients, 27 (5.3%) met these criteria (global cohort). All patients were assessed postoperatively with dimercaptosuccinic acid scintigraphy (DMSA). A difference in relative kidney function of >10% was considered abnormal. Pre- and postoperative comparative DMSA analyses were electively obtained for 9 patients (kidney function cohort). A t test was used to assess the numeric variables, and the chi-square test or Fisher's exact test was used for categorical variables. Two-tailed P<.05 was considered statistically significant. Stones were diagnosed by radiologic abdominal evaluation for nonurologic diseases in 40% and after previous nephrolithiasis treatment in 33%. The primary therapy was ureterolithotripsy in 88%. The mean follow-up time was 23 months. The overall ureteral stone-free rate after 1 and 2 procedures was 96% and 100%, respectively. In the global cohort, the mean pre- and postoperative serum creatinine levels were similar (P=.39), and the mean postoperative function on DMSA was 31%. In the kidney function cohort, no difference was found between the pre- and postoperative DMSA findings (22%±12.1% vs 20%±11.8%; P=.83) and serum creatinine (0.8±0.13 mg/dL vs 1.0±0.21 mg/dL; P=.45). Silent ureteral stones are associated with decreased kidney function present at the diagnosis. Hydronephrosis tends to diminish after stone removal, and kidney function remains unaltered.