Preoperative Renal Dysfunction Research Articles

Early administration of levosimendan is associated with improved kidney function after cardiac surgery - a retrospective analysis.

BackgroundSeveral animal studies suggest beneficial effects on kidney function upon administration of levosimendan. As recent data from clinical studies are heterogeneous, we sought to investigate whether levosimendan is associated with improved postoperative kidney function in cardiac surgery patients with respect to timing of its administration.MethodsRetrospective, single centre, observational analysis at a university hospital in Berlin, Germany. All adult patients without preoperative renal dysfunction that underwent coronary artery bypass grafting and/or valve reconstruction/replacement between 01/01/2007 and 31/12/2011 were considered for analyses.ResultsOut of 1.095 included patients, 46 patients were treated with levosimendan due to a severely reduced left ventricular systolic function preoperatively (LVEF < 35%) and/or clinical signs of a low cardiac output syndrome. Sixty-one percent received the drug whilst in the OR, 39% after postoperative intensive care unit admission. When levosimendan was given immediately after anaesthesia induction, creatinine plasma levels (p = 0.009 for nonparametric analysis of longitudinal data in a two-factorial design) and incidence of postoperative renal dysfunction (67.9% vs. 94.4%; p = 0.033) were significantly reduced in contrast to a later start of treatment. In addition, duration of renal replacement therapy was significantly shorter (79 [35;332] vs. 272 [132;703] minutes; p = 0.046) in that group.ConclusionsPostoperative kidney dysfunction is a common condition in patients under going cardiac surgery. Patients with severely reduced left ventricular function and/or clinical signs of a low cardiac output syndrome who preoperatively presented with a normal kidney function may benefit from an early start of levosimendan administration, i.e. immediately after anaesthesia.Trial registrationClinicaltrials.gov-ID: NCT01918618.Electronic supplementary materialThe online version of this article (doi:10.1186/s13019-014-0167-8) contains supplementary material, which is available to authorized users.

Clinical Impact of Mild Acute Kidney Injury After Cardiac Surgery

Dialysis-dependent renal failure occurs infrequently after cardiac surgery but leads to substantial morbidity and mortality. In contrast, milder degrees of acute kidney injury (AKI), based on small increases in serum creatinine, occur frequently but the independent impact of mild AKI on outcome remains unclear. Between January 2010 and December 2012, 3,869 consecutive patients undergoing cardiac surgery comprised the study cohort. Acute kidney injury was defined according to the AKI Network criteria as stage I, II, or III. A nonparsimonious multivariable logistic regression model including preoperative and intraoperative variables was constructed to determine a propensity score for the development of stage I AKI followed by a greedy matching algorithm to create 1:1 propensity-matched pairs. The incidence of stage I AKI in the entire cohort was 22.4%. Stage I AKI patients were more likely to be older; to have diabetes mellitus, hypertension, preoperative renal dysfunction, and poorer left ventricle function; and to require more urgent surgery and longer cardiopulmonary bypass. After propensity matching, the 833 matched pairs were similar in terms of all of the above characteristics (all p > 0.5). Within the matched cohort, AKI patients had higher mortality (2.6% versus 1.2%, p = 0.01), higher incidence of neurologic dysfunction (15.2% versus 8.1%, p < 0.001), and longer duration of mechanical ventilation (41.7 ± 125.0 versus 19.3 ± 58.6 hours, p < 0.001). Intensive care unit stay (5.2 ± 10.7 versus 2.7 ± 3.8 days, p < 0.0001), and hospital length of stay (17.9 ± 20.1 versus 14.7 ± 18.3 days, p = 0.0007) was significantly longer for matched AKI patients. Patients with even mild degrees of AKI have increased mortality and morbidity compared with their matched counterparts. Interventions that prevent or mitigate AKI after cardiac surgery can yield substantial clinical benefit.

Side Biting vs Cross Clamping For Hepatic Venous-Caval Anastomosis in Living Donor Liver Transplantation.

Piggyback technique has shown to potentially have a protective effect on renal function in whole liver deceased donor liver transplantation when compared to conventional caval cross clamping for venous reconstruction. We investigated if a similar protective effect on kidney function could be demonstrated in the live related liver donor scenario. Methods Retrospective analysis of prospectively collected data of transplants performed between December 2012 to December 2013 was performed. Right, middle and inferior hepatic veins were anastomosed to the inferior vena cava with the cava cross clamped in group A and using a side biting, partially occluding clamp in group B. Renal function was assessed by measurement of serum creatinine preoperatively and daily after transplant for the first 14 days and when indicated subsequently. Adequacy of venous outfolw was assessed by doppler ultrasound (US) performed daily for the first 5 days and when clinically indicated subsequently. Results 31 transplants were performed in this period. There were 16 patients in group A and 15 in group B. 14 (45%) patients had preoperative renal dysfunction, 8 in group A and 6 in group B. Patients in group B showed significantly greater renal dysfunction on days 2 and 3, (day 2: 1.55 vs 1.01, p=0.04, day 3: 1.57 vs 0.95, p= 0.49) as compared to patients in group A. This was true for absolute creatinine values as well as increase from the base line. When we looked at the subgroup with preoperative renal dysfunction, patients in group B showed greater renal dysfunction in the immediate post operative period. This was seen by an increase in absolute serum creatinine as well as an increase from baseline as compared to group A, even though it did not reach statistical significance (day 2: 1.48 vs 1.19, p=0.35 day 3: 1.49 vs 1.18, p=0.89). The warm ischemia time was higher in group B (Mean 48 minutes vs 39 minutes). There was no outflow obstruction in either group and both groups showed a similar pattern on doppler US. Conclusion Contrary to expectations, our study shows that use of side biting clamps for outflow reconstruction in living donor liver transplantation has a detrimental effect on renal function.

A novel balanced isotonic sodium solution vs normal saline during major surgery in children up to 36months: a multicenter RCT.

The use of isotonic electrolytic solutions for the intraoperative fluid management in children is largely recognized, but the exact composition still needs to be defined. The primary objective of this randomized controlled open trial was to compare the changes in chloride plasma concentration using two intraoperative isotonic fluid regimens (Sterofundin vs. normal saline, both added with 1% of glucose) in children undergoing major surgery. Secondary objectives were to compare changes in other electrolytes, renal function, and the occurrence of hypoglycemia. Children aged between 1 and 36 months, scheduled for major surgery, were randomized to receive Sterofundin or saline during the intraoperative time. Children with preoperative electrolyte abnormalities, hemodynamic instability, and severe renal or hepatic dysfunction were excluded. The primary outcome was the Δ of Cl(-) (Δ = change in plasma concentration between post- and pre-infusion), and secondary outcomes included Δ of other electrolytes and intraoperative hypoglycemia. A total of 240 patients were included in the two study sites and randomized to receive Sterofundin plus 1% glucose or normal saline plus 1% glucose, in a open fashion (229 were finally analyzed). Δ of Cl- and Mg++ was statistically less relevant in patients who received intraoperative Sterofundin, and Δ of the other electrolytes was comparable between the two study groups. Relative risk of hyperchloremia was significantly higher when large volumes were infused (over than 46.7 ml·kg(-1) ), regardless of type of crystalloid infused. Hypoglycemia occurred in two of 229 patients. Sterofundin is safer than normal saline in protecting young children undergoing major surgery against the risk of increasing plasma chlorides and the subsequent metabolic acidosis.

High levels of free haemoglobin in neonates and infants undergoing surgery on cardiopulmonary bypass.

Haemolysis is known to occur during surgery on cardiopulmonary bypass (CPB) and to be responsible for kidney injury. The aim of this study was to assess, in a cohort of infants, the reference levels of free haemoglobin (fHb) and their change over time postoperatively; the predicting variables of haemolysis in the intraoperative phase; and the association between fHb and renal function. A retrospective analysis in infants undergoing surgery on CPB was conducted. Children with preoperative renal dysfunction and need for extracorporeal membrane oxygenation support were excluded. fHb was sampled before and after CPB and on the first 2 postoperative days (POD). Twenty-two patients with a median (interquartile) age of 111 (63-184) days and Aristotle score of 8 (6.4-9) were enrolled. fHb had a baseline value of 29 (24-41) mg/dl, peaked to 75 (65-109) mg/dl at CPB weaning and returned to 35 (30-55) mg/dl on POD 2 (P <0.0001). The median normalized index of haemolysis was 0.15 (0.09-0.19) g of fHb per 100 l of pumped blood. A multivariable regression model showed that, at CPB weaning, fHb levels were independently associated with left atrial venting flow (P = 0.02), and that CPB time remained the only independent variable (P = 0.034), when left atrial venting was excluded from the analysis. Acute kidney injury (AKI) occurred in 10 patients (45%). fHb levels in the 48 post-CPB hours were not significantly different between AKI and non-AKI patients: However, a significant correlation was present between creatinine on POD1 and CPBw-fHb (r = 0.48; P = 0.045); and between cystatin C on POD1 and CPBw-fHb (r = 0.58; P = 0.02). A high rate of fHb is released during paediatric surgery with CPB in infants. fHb mainly depends on the left atrial venting flow rate and CPB duration. However, such peaks of fHb levels were not associated with renal dysfunction.

Surgical results of reoperative tricuspid surgery: analysis from the Japan Cardiovascular Surgery Database

Tricuspid valve insufficiency (TI) following cardiovascular surgery causes right-side heart failure and hepatic failure, which affect patient prognosis. Moreover, the benefits of reoperation for severe tricuspid insufficiency remain unclear. We investigated the surgical outcomes of reoperation in TI. From the Japan Cardiovascular Surgery Database (JACVSD), we extracted cases who underwent surgery for TI following cardiac surgery between January 2006 and December 2011. We analysed the surgical outcomes, specifically comparing tricuspid valve replacement (TVR) and tricuspid valve plasty (TVP). Of the 167 722 surgical JACVSD registered cases, reoperative TI surgery occurred in 1771 cases, with 193 TVR cases and 1578 TVP cases. The age and sex distribution was 684 males and 1087 females, with an average age of 66.5 ± 10.8 years. The overall hospital mortality was 6.8% and was significantly higher in the TVR group than in the TVP group (14.5 vs 5.8%, respectively; P < 0.001). Incidences of dialysis, prolonged ventilation and heart block were also significantly higher in the TVR group than in the TVP group. Logistic regression analysis revealed that the risk factors of hospital mortality were older age, preoperative renal dysfunction, preoperative New York Heart Association Class 4, left ventricular dysfunction and TVR. Surgical outcomes following reoperative tricuspid surgery were unsatisfactory. Although TVR is a last resort for non-repairable tricuspid lesions, it carries a significant risk of surgical mortality. Improving the patient's preoperative status and opting for TVP over TVR is necessary to improve the results of reoperative tricuspid surgery.

Perioperative renal function and surgical outcome

A large proportion of patients undergoing surgery have coexisting chronic kidney disease, placing them at greater risk of postoperative morbidity and mortality. The purpose of this review is to review the recent developments in how renal function is estimated, how this relates to surgical outcomes, and how this has been applied clinically. Recent developments in defining chronic kidney disease have coincided with an increased recognition of the prognostic importance of even mild preoperative renal dysfunction and the incorporation of more refined estimates of renal function into one of the most widely used risk prediction scores for cardiac surgery. In addition, several novel markers appear to hold promise as better predictors of perioperative outcome in general and acute kidney injury in particular. Improved accuracy in defining kidney disease will aid clinicians in identifying higher risk patients, and aid earlier diagnosis of acute kidney injury. Further research is required, specifically on the implications of kidney disease in noncardiac surgical patients, and how defining renal function before and after surgery can aid in preventive strategies.

Effects of right ventricular morphology and function on outcomes of patients with degenerative mitral valve disease

The study objective was to investigate whether, in patients undergoing surgery for degenerative mitral valve disease, associated right ventricular remodeling and dysfunction are stronger determinants of preoperative organ dysfunction and prognosis than functional tricuspid regurgitation. From January 2001 to January 2011, 4197 patients underwent primary mitral valve surgery for degenerative valve disease at Cleveland Clinic. Using a quasi-experimental enriched study design, 781 patients were randomly selected within each grade of functional tricuspid regurgitation. Renal function was assessed by glomerular filtration rate and blood urea nitrogen, and hepatic function was assessed by Model for End-stage Liver Disease (MELD) score. Preoperative and postoperative right ventricular morphology and function were measured de novo on stored echocardiographic images. To assess survival, 3471 patient-years of follow-up data were available for analysis. Several preoperative right ventricular variables, but not functional tricuspid regurgitation grade (P>.05), were associated with preoperative renal and hepatic dysfunction, but neither was associated with early mortality (<6 months after surgery). However, worse preoperative right ventricular myocardial performance index (P=.001), but not functional tricuspid regurgitation grade (P>.2), was among the risk factors for later mortality. Postoperative unadjusted right ventricular function, but not functional tricuspid regurgitation grade (P≥.2), was associated with both early (P=.04) and later (P=.01) mortality, but in multivariable analysis appeared to be a surrogate for worse preoperative condition. Together with patient comorbidities and operative factors, right ventricular morphology and function are associated more strongly with preoperative organ dysfunction and prognosis than is functional tricuspid regurgitation severity in patients undergoing surgery for degenerative mitral valve disease. Our previous study showed that tricuspid valve repair remains the most effective treatment to improve right ventricular function.

腹部大動脈瘤術後の腎機能低下に対する予測因子の検討

Whether endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is a relative contraindication in patients with preoperative renal dysfunction (Pre-RD), remains controversial because the contrast medium may induce nephrotoxicity. In this study 1658 patients were treated at ten Japanese medical centers between January 2005 and March 2011 (Open surgery (OS) vs. EVAR: n = 1270 vs. n = 388). They were retrospectively analyzed. Multiple logistic regression analysis (MLRA) with pre- and intra-operative variables was applied to all patients. The endpoints induced onset of new dialysis and postoperative renal dysfunction (Post-RD), were defined as a 50% decrease or more from the preoperative estimated glomerular filtration rate (eGFR) level. Results: Early mortality, Post-RD, incidence of new dialysis in all patients were 1.6% (OS: EVAR = 1.9%:0.8%), 6% (OS: EVAR = 8%:2.3%) and 1.4% (OS: EVAR = 1.5%:1.0%) respectively. MLRA identified operation time, clamp of renal artery as risk factors for Post-RD, and operation time and Pre-eGFR level as risk factors for new dialysis. Conclusion: Although Post-RD was more frequently observed in the OS group, MLRA showed that the choice of OS or EVAR was not a risk factor for Post-RD and new dialysis. It was strongly suggested that using contrast medium during EVAR is not a contraindication to AAA repair in patients with Pre-RD. (This article is a translation of J Jpn Coll Angiol 2014; 54: 13–18.)

Anesthetic Technique and Acute Kidney Injury in Endovascular Abdominal Aortic Aneurysm Repair

Prior studies suggest that general anesthesia (GA) is associated with worse cardiopulmonary outcomes after endovascular abdominal aortic aneurysm repair (EVAR). Patients undergoing EVAR are at a high risk of developing perioperative acute kidney injury (AKI), and the relationship between anesthetic technique and AKI in these patients is not well-characterized. The authors sought to determine if anesthetic technique affected the risk of AKI in patients undergoing EVAR. Retrospective, observational cohort study analyzed using a multivariate logistic regression model to assess the effects of anesthetic technique on renal outcome. Multiple institutions, mainly in North America. Patients in the American College of Surgeons National Surgical Quality Improvement Program from 2005-2010 undergoing EVAR. The authors investigated the association between anesthetic techniques, comparing GA to alternative (non-GA) techniques, and AKI. AKI was defined as an increase in the creatinine level of>2 mg/dL and/or dialysis. Of 13,026 patients, 84.4% underwent GA and 15.6% underwent non-GA techniques. AKI developed in 2.0% of the GA group and 1.4% of the non-GA group (unadjusted odds ratio [OR] 1.43, p = 0.075; adjusted OR [aOR] 1.00, p = 0.99). Risk factors for AKI include ASA class, ruptured aneurysm, preoperative renal dysfunction, symptomatic cardiovascular disease, and perioperative blood transfusion. Anesthetic technique is not independently associated with the risk of AKI in patients undergoing EVAR.

Impact of varying degrees of renal dysfunction on transcatheter and surgical aortic valve replacement

Renal impairment portends adverse outcomes in patients undergoing valvular heart surgery. Therelationship between renal dysfunction in patients undergoing transcatheter aortic valve replacement (TAVR) is incompletely understood. A retrospective review of 1336 patients undergoing surgical aortic valve replacement (SAVR; 2002-2012) and 321 patients undergoing TAVR (2007-2012) was performed. Patients were divided into 3 glomerular filtration rate (GFR) groups: GFR greater than 60 mL/min, GFR 31 to 60 mL/min, and GFR 30 mL/min or less. Logistic and linear regression analysis was performed to estimate the TAVR effect on outcomes. Risk adjustments were made using the Society for Thoracic Surgeons (STS) predicted risk of mortality (PROM). TAVR patients were older (82 vs 65 years; P<.001), had a poorer ejection fraction (48% vs 53%; P<.001), were more likely female (45% vs 41%; P=.23), and had a higher STS PROM (11.9% vs 4.6%; P<.001). In-hospital mortality rates for TAVR and SAVR were 3.5% and 4.1%, respectively (P=.60), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio=.52, P=.06). In SAVR patients, worsening preoperative renal failure was associated with increased in-hospital mortality (P=.004) and hospital (P<.001) and intensive care unit (ICU) (P<.001) lengths of stay. In contrast, worsening renal function did not influence in-hospital mortality (P=.78) and hospital (P<.23) and ICU (P=.88) lengths of stay in TAVR patients. Worsening renal function was associated with increased in-hospital mortality, hospital length of stay, and ICU length of stay in SAVR patients, but not in TAVR patients. This unexpected finding may haveimportant clinical implications in patients with aortic stenosis and preoperative renal dysfunction.

GW24-e0441 Risk factors for the development of renal dysfunction after heart transplantation

ObjectivesTo access the prevalence and risk factors responsible for renal dysfunction after heart transplantation (HT) in Chinese single centre.MethodsWe studied 248 consecutive adult patients who had undergone HT between June...

Relation Between Preoperative Renal Dysfunction and Cardiovascular Events (Stroke, Myocardial Infarction, or Heart Failure or Death) Within Three Months of Isolated Coronary Artery Bypass Grafting

Renal dysfunction is related to long-term mortality and myocardial infarction after coronary artery bypass grafting (CABG). We aimed to investigate the association between preoperative renal dysfunction and early risk of stroke, myocardial infarction, or heart failure after CABG. From the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry, we included all 36,284 patients who underwent primary isolated CABG from 2000 to 2008 in Sweden. The Swedish National Inpatient Registry was used to obtain the primary end point, which was rehospitalization for stroke, myocardial infarction, or heart failure ≤90 days after CABG. Logistic regression models were used to estimate the risk for the primary outcome and the secondary outcome of death from any cause, while adjusting for confounders. During 90 days of follow-up, there were 2,462 cardiovascular events and 617 deaths. In total, 17% of patients developed acute kidney injury postoperatively. Odds ratios with 95% confidence intervals for cardiovascular events after adjustment for age, gender, atrial fibrillation, left ventricular ejection fraction, diabetes mellitus, peripheral vascular disease, and history of myocardial infarction, heart failure, or stroke was 1.24 (1.06 to 1.45) in patients with an estimated glomerular filtration rate of 15 to 45 ml/min/1.73 m(2) but became nonsignificant after acute kidney injury was introduced into the statistical model. The risk of death was significantly increased in patients with estimated glomerular filtration rate of 15 to 45 ml/min/1.73 m(2) (odds ratio 1.76, 95% confidence interval 1.38 to 2.25) even after adjustment for all confounders. Renal dysfunction was associated with all-cause mortality but not with cardiovascular events during the first 3 postoperative months after primary isolated CABG.

Feasibility and safety of minimized cardiopulmonary bypass in major aortic surgery

Conventional cardiopulmonary bypass causes haemodilution and is a trigger of systemic inflammatory reactions, coagulopathy and organ failure. Miniaturized cardiopulmonary bypass has been proposed as a way to reduce these deleterious effects of conventional cardiopulmonary bypass and to promote a more physiological state. The use of miniaturized cardiopulmonary bypass has been reported in low-risk patients undergoing valve and coronary artery bypass graft (CABG) surgery. However, little is known about its application in major aortic surgery. From February 2007 to September 2010, 49 patients underwent major aortic surgery using the Hammersmith miniaturized cardiopulmonary bypass (ECCO, Sorin). Data were extracted from medical records to characterize preoperative comorbidities (EuroSCORE), perioperative complications and the use of blood products. The same data were collected and described for 328 consecutive patients having similar surgery with conventional cardiopulmonary bypass at the Bristol Heart Institute, our twinned centre, during the same period. The miniaturized cardiopulmonary bypass group had a median EuroSCORE of 8 [inter-quartile range (IQR): 5-11], 13% had preoperative renal dysfunction and 20% of operations were classified as emergency or salvage. Thirty-day mortalities were 6.4; and 69, 67 and 74% had ≥ 1 unit of red cells, fresh frozen plasma (FFP) and platelets transfused, respectively. Eight percent of patients experienced a renal complication, and 8% a neurological complication. The conventional cardiopulmonary bypass group was similar, with a EuroSCORE of 8 (IQR: 6-10); 30-day mortalities were 9.4; and 68, 62 and 74% had ≥ 1 unit of red cells, FFP and platelets transfused, respectively. The proportions experiencing renal and neurological complications were 14 and 5%. Our experience suggests that miniaturized cardiopulmonary bypass is safe and feasible for use in major aortic cardiac surgery. A randomized trial is needed to evaluate miniaturized cardiopulmonary bypass formally.

Impact of anesthesia technique on the incidence of major complications after open aortic abdominal surgery: a cohort study

Study ObjectiveTo determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery. DesignRetrospective analysis of a prospective cohort. SettingsOperating room, intensive care unit, and Postanesthesia Care Unit of a university hospital. MeasurementsData from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded. Main ResultsPatients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99). ConclusionsThis single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.

685 DETECTION OF FACTORS AFFECTING EARLY BLADDER RECURRENCE AFTER NEPHROURETERECTOMY IN PATIENTS WITH N0M0 UPPER URINARY TRACT UROTHELIAL CARCINOMA

You have accessJournal of UrologyUrothelial Cancer: upper Tract Tumors (I)1 Apr 2013685 DETECTION OF FACTORS AFFECTING EARLY BLADDER RECURRENCE AFTER NEPHROURETERECTOMY IN PATIENTS WITH N0M0 UPPER URINARY TRACT UROTHELIAL CARCINOMA Kenji Kuroda, Junichi Asakuma, Akio Horiguchi, Shinsuke Tasaki, Akinori Sato, Kenji Seguchi, Keiichi Ito, and Tomohiko Asano Kenji KurodaKenji Kuroda Tokorozawa, Saitama, Japan More articles by this author , Junichi AsakumaJunichi Asakuma Tokorozawa, Saitama, Japan More articles by this author , Akio HoriguchiAkio Horiguchi Tokorozawa, Saitama, Japan More articles by this author , Shinsuke TasakiShinsuke Tasaki Tokorozawa, Saitama, Japan More articles by this author , Akinori SatoAkinori Sato Tokorozawa, Saitama, Japan More articles by this author , Kenji SeguchiKenji Seguchi Tokorozawa, Saitama, Japan More articles by this author , Keiichi ItoKeiichi Ito Tokorozawa, Saitama, Japan More articles by this author , and Tomohiko AsanoTomohiko Asano Tokorozawa, Saitama, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.241AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The bladder recurrence after nephroureterectomy is one of the major problems in patients with localized upper urinary tract (UUT) urothelial carcinoma (UC). Early recurrence from the time of radical surgery has especially been reported to be indicative of the repetitive recurrence of bladder tumors, which might lead to conditions requiring radical cystectomy in the future. In the present study, we evaluated factors to predict early bladder recurrence after nephroureterectomy in patients with localized UUT-UC. METHODS Our retrospective study includes 108 UUT-UC patients for whom neither preoperative radiological examination nor pathological examination of surgical specimens indicated distant or lymph node metastasis (N0M0). Forty three out of 108 patients had bladder recurrence after surgery and twelve had early intravesical recurrence. Early bladder recurrence was defined as intravesical tumor occurrence within six months after surgery. We evaluated clinicopathological parameters by using the Cox proportional hazards model, Fisher's exact probability test, multiple logistic regression analysis, and a log-rank test with Kaplan-Meier plots. We used the estimated glomerular filtration rate (eGFR: mL/min/1.73 m2) as an indicator of renal function. RESULTS The results from the Cox proportional hazards model revealed that only bladder tumor occurrence before or at the time of nephroureterectomy was significantly (p = 0.0007) associated with early bladder recurrence after nephroureterectomy. Fisher's exact probability test indicated that previous or concurrent occurrence of bladder tumors (p = 0.0032), and eGFR of less than 30 mL/min/1.73 m2 before surgery (preoperative eGFR < 30) (p = 0.0267) were independent factors for early bladder recurrence. We evaluated clinicopathological parameters from these findings, using multiple logistic regression analysis, and determined the condition of preoperative eGFR < 30 with bladder tumor occurrence before or at the time of nephroureterectomy was the only independent factor for early bladder recurrence after surgery (p = 0.0131). The Kaplan-Meier plot and log-rank test also revealed a significant difference in the time for bladder recurrence to occur in patients with and without the condition noted above (p = 0.0001). CONCLUSIONS We conclude that N0M0 UUT-UC patients with preoperative or perioperative bladder tumor and renal dysfunction need to be cared for early and possibly repetitive bladder recurrence after nephroureterectomy. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e281 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kenji Kuroda Tokorozawa, Saitama, Japan More articles by this author Junichi Asakuma Tokorozawa, Saitama, Japan More articles by this author Akio Horiguchi Tokorozawa, Saitama, Japan More articles by this author Shinsuke Tasaki Tokorozawa, Saitama, Japan More articles by this author Akinori Sato Tokorozawa, Saitama, Japan More articles by this author Kenji Seguchi Tokorozawa, Saitama, Japan More articles by this author Keiichi Ito Tokorozawa, Saitama, Japan More articles by this author Tomohiko Asano Tokorozawa, Saitama, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Preoperative renal dysfunction and clinical outcomes of cardiac surgery in octogenarians

BackgroundThe proportion of elderly individuals is growing and the prevalence of chronic kidney disease (CKD) among elderly people undergoing cardiac surgery is increasing constantly. The aim of this study was to determine the influence of different degrees of preoperative renal dysfunction on postoperative outcomes in patients older than 80years of age. MethodsThis is an observational study that included adult patients undergoing cardiac surgery in which data were collected prospectively. Patients were divided into groups according to their preoperative plasma creatinine and eGFR levels. ResultsFrom February 1997 to January 2010, 318 octogenarians underwent cardiac surgery. Of these, 140 patients (44%) had abnormal preoperative creatinine levels. A significantly higher incidence of postoperative sepsis (4% vs. 17%, p 0.03), CVA (1% vs. 6%, p 0.03), and prolonged hospital stay (16±13 vs. 20±16days, p 0.04) were detected in patients with preoperative kidney dysfunction. Subgroup analysis revealed that preoperative CKD stage IV (eGFR 15–30ml/min/1.73m2) but not CKD stage III (eGFR 30–60ml/min/1.73m2) and preoperative creatinine >1.8mg/dl were independently associated with increased incidence of postoperative CVA (OR 4; 95% CI 0.07–0. 8, p=0.05 for eGFR, and OR 7.8; 95% CI 1.2–60, p=0.003 for creatinine). However, no significant increment in postoperative mortality with decreasing eGFR or increasing preoperative creatinine was demonstrated. ConclusionsA substantial increase in the risk of postoperative CVA and sepsis, but not mortality, was demonstrated in octogenarians with advanced but not mild degrees of preoperative CKD. Compared to younger patients, a high burden of comorbidities in octogenarians may have a greater influence on outcomes post cardiac surgery than impaired renal function. Our data may provide a rationale for modified risk stratification in octogenarian candidates for cardiac surgery.

Impact of perioperative renal dysfunction in heart transplantation: Combined heart and kidney transplantation could help to reduce postoperative mortality

Renal dysfunction is a frequent problem in heart failure patients. We aimed to investigate the predictors of mortality after heart transplantation and the impact of perioperative renal dysfunction on short-term and long-term prognosis. We analyzed the outcomes of patients undergoing isolated heart transplantation (IHT, n=62) and combined heart-kidney transplantation (CHKT, n=5) between October 2007 and May 2012. Among all patients, 55.2% had preoperative renal dysfunction. Compared with the IHT group, the CHKT group had a lower estimated glomerular filtration rate (p=0.001), and higher proportion of diabetes (p=0.008), hypertension (p=0.010), renal failure (p=0.036), and greater incidence of preoperative continuous renal replacement therapy (CRRT) (p=0.025). Despite unfavorable baseline conditions in the CHKT group, there was no postoperative mortality. Early 30-day postoperative mortality only occurred in the IHT group (5 patients, 8.1%). In multivariate analysis, persistent renal dysfunction (HR 29.356, p<0.001), donor heart ischemic time (HR 1.014, p=0.005), and duration of mechanical ventilation (HR 1.012, p=0.026) were significant predictors of overall mortality. The patients with persistent renal dysfunction at 1 month after transplantation showed significantly lower survival rates compared to the patients with complete renal recovery (10% vs. 93% at 1 year, p<0.001). In the long-term follow-up of patients who had preoperative renal dysfunction, IHT showed only 64% survival, whereas CHKT showed 100%. Renal dysfunction was a common manifestation in heart transplantation recipients. Persistent renal dysfunction after transplantation was the most powerful independent predictor of overall mortality. CHKT could help to reduce postoperative mortality in end-stage heart failure patients with renal dysfunction.

Female-to-Male Match Predicted Poor Survival After Living-Donor Liver Transplantation—Some Issues Needed to be Clarified

We read with great interest the recent article by Yoshizumi et al. (1), which evaluated the risk factors that increased mortality after living-donor liver transplantation. Their study found that male recipients of transplants from female donors (FM), those having pretransplantation diabetes mellitus (DM), and having a model for end-stage liver disease score of 20 or more were independent risk factors that predicted poor survival for LDLT recipients. Nevertheless, close inspection of the study revealed some methodological issues that are worth mentioning and clarifying. First, Yoshizumi et al. (1) reported 335 cases of living-donor liver transplantation (LDLT), which included 180 cases of benign end-stage liver diseases and 155 cases of hepatocellular carcinoma (HCC). HCC accounts for nearly half of the cohort patients, and HCC recurrence is the main cause of death in the study (14/80). However, none of the risk factors that increased mortality after LDLT in the study, to our knowledge, is related to HCC recurrence. Tumor recurrence is the main cause of death after liver transplantation for HCC, as demonstrated by previous studies (2, 3). Not surprisingly, some factors associated with biologic aggressiveness, such as tumor number, tumor differentiation grade, presence of a peritumoral capsule, and microscopic vascular invasion, were independent predictors of survival (4–7). In other words, tumor biology determines outcome after liver transplantation for HCC, whereas for benign end-stage liver diseases, the factors that predicted survival were model for end-stage liver disease scores and Child-Pugh category (8–10). Recently, Li et al. (11) reported that preoperative renal dysfunction, intraoperative red blood cell transfusions of greater than 5 U, and female-to-male gender match were independent risk factors that predicted poor survival for LDLT recipients with benign end-stage liver diseases. Therefore, it is not very proper to analyze the factors that predicted poor survival of LDLT recipients, which were mixed by benign end-stage liver diseases and HCC. The authors should separately analyze the factors that predicted survival of LDLT for HCC and benign end-stage liver diseases. Second, the authors reported that the 1-year, 3-year, and 5-year survival rates after LDLT for HCC were 91.7%, 80%, and 69%, whereas rates for benign end-stage liver diseases were 80.5%, 74.7%, and 73.0% (in Table 2 of Yoshizumi et al. (1)). Patients in the HCC group showed higher 1-year, 3-year, 5-year survival rates compared with patients in the benign end-stage liver diseases group, although this difference was not statistically significant (P=0.077). Did the authors consider that the long-term survival rates of LDLT for HCC were equal to LDLT for benign liver diseases? What criteria were used to screen HCC patients for LDLT in the authors’ institute? Milan criteria, University of California San Francisco criteria, or other criteria? Third, the distribution of the HCC was markedly skewed among the four groups (in Table 1 of Yoshizumi et al. (1)), and the FM group owned the highest proportion of HCC in the four groups (P<0.001). Although the HCC was not identified as a risk factor that predicted poor survival in the study, a subgroup analysis in the FM group should be performed according to the HCC to exclude the effect of HCC on survival. Moreover, the pretransplantation DM is another risk factor that predicted poor survival after LDLT. Similarly, the distribution of the pretransplantation DM was markedly skewed among the four groups (in Table 1 of Yoshizumi et al. (1)). The female donor to female recipient group owned the lowest proportion of pretransplantation DM (0%), whereas the FM group owned a significantly higher proportion of pretransplantation DM (20.33%) (P=0.001). In contrast, the FM group showed significantly worse patient survival rates compared with the female donor to female recipient group (P<0.01). In order to exclude the effect of pretransplantation DM on survival in the FM group, a subgroup analysis should be performed according to the pretransplantation DM. The authors can perform a subgroup analysis in the FM group according to the graft weight-standard liver weight ratio. Why did the authors not perform a subgroup analysis in the FM group according to the pretransplantation DM?

L’insuffisance rénale aiguë après chirurgie cardiaque : évaluation des critères RIFLE

IntroductionAcute renal failure is a common complication is a common complication in cardiac surgery under cardiopulmonary bypass. It is associated with increased morbidity and mortality. Acute kidney injury (AKI) is a clinical entity encompassing the entire spectrum of acute renal failure, since minor alterations to the need for renal replacement therapy. The RIFLE criteria have been proposed for defining and classifying AKI. The aim of our study was to apply the RIFLE to a population of patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and to assess its relevance in terms of risk factor for hospital mortality compared to other risk factors. MethodsIn this prospective observational study, we included patients who were operated for programmed cardiac surgery. The assay of blood creatinine was performed at admission, after surgery and daily for 5 days post-surgery. The AKI was evaluated according to the criteria of classification RIFLE. The patients were divided into three levels of severity based on plasmatic creatinine (R: Risk=creatinine×1.5; I: Injury=creatinine×2; F: Failure=creatinine×3). We have analyzed the different perioperative parameters and we sought associations with the occurrence of AKI. We also studied the impact of AKI on length of stay in ICU and mortality early and late. ResultsOne hundred and thirty-six patients were included. AKI was diagnosed in 17.6% of patients (RIFLE-R: 8.8%, RIFLE-I: 5.9% and RIFLE-F: 2.9%). AKI significantly prolongs the duration of ICU stay (7±3.8 versus 5±2.3 days; P=0.02). RIFLE-R patients had a mortality of 8.3%, compared to 12.5% for I and 50% for F. Patients without PORD had a mortality of 1.8%. In univariate analysis, age, the EURO score, preoperative renal dysfunction, duration of aortic clamping, duration of CPB and C-reactive protein (CRP) were significantly associated with the occurrence of AKI. In multivariate analysis only preoperative renal dysfunction (clearance less than 63mL/min) and CRP greater than 158mg/L were found as independent factors of occurrence of AKI. ConclusionRIFLE classification seems to be a reliable way to detect acute renal failure and to classify its severity. The AKI is a common complication and is associated with increased morbidity and mortality. Identifying the risk factors allows a better prevention strategy.