Preoperative Chronic Kidney Disease Stage Research Articles

Bariatric surgery and the diseased kidney: a 5-year assessment of safety and postoperative renal outcomes.

Obesity and its related medical conditions are well-established contributors to the development of chronic kidney disease (CKD). Metabolic and bariatric surgery (MBS), including procedures such as sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), is a potential intervention for these individuals. However, the heightened risk of postoperative complications casts doubts on the suitability of MBS in this population. Our aim is to evaluate the long-term safety, anthropometric and renal outcomes of MBS in patients with CKD. A retrospective review of patients who underwent primary laparoscopic MBS with a BMI ≥ 35kg/m2 and a preoperative diagnosis of stage 2 to 5 CKD. Criteria for CKD diagnosis and staging were based on estimated glomerular filtration rate measurements in accordance with established guidelines. Anthropometric and renal outcomes were measured at 3-, 6-, 12-, 24- and 60-months postoperatively. A total of 302 patients (177 SG, 125 RYGB) were included. RYGB was preferred for patients with stage 3 CKD, while SG was more common in stages 4 and 5. At 5-year follow-up, percentage of total weight loss was higher in the RYGB cohort compared to SG (25.1% vs. 18.6%, p = 0.036). Despite SG patients having more advanced CKD, the incidence of late complications was significantly higher following RYGB, with 11 incidents (8.8%), compared to the SG cohort with only 4 cases (2.3%) (p = 0.014). In those with preoperative CKD stage 3, 76 patients (43.2%) improved to stage 2, with another 9 patients (5.1%) improving further to stage 1. Of all patients, 63 (20.8%) eventually received a successful renal transplant. MBS is an effective strategy for sustained weight loss in patients with CKD with acceptable complications rates. RYGB leads to a higher percentage of overall weight loss, albeit with an elevated likelihood of late surgical complications. Future studies are needed to determine the safety of MBS in this demographic.

Prevalence and oncologic impact of chronic kidney disease for upper tract urothelial carcinoma in endemic area

ObjectiveThis study aimed to assess the impact of preoperative chronic kidney disease (CKD) on the oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) who underwent standard radical nephroureterectomy (RNU). MethodsA total of 1172 UTUC patients who received RNU at a single center in Taiwan between February 2005 and August 2019 were included. The patients were categorized into two groups based on their preoperative CKD stage: CKD stage ≤3 (811 patients) and CKD stage >3 (361 patients). The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. The study investigated the oncological outcomes, including intravesical recurrence, non-urothelial recurrence, and cancer-specific mortality, stratified by preoperative CKD status. ResultsThe main findings indicated that UTUC patients with CKD stage >3 in Taiwan exhibited a higher proportion of females (p < 0.001), a greater history of concurrent bladder cancer (p = 0.003), more multifocal tumor behavior (p < 0.001), a higher incidence of carcinoma in situ (p = 0.008), increased rates of intravesical recurrence (p < 0.001), a lower prevalence of smoking history (p = 0.003), lower utilization of adjuvant chemotherapy (p < 0.001), reduced occurrence of non-urothelial recurrence (p < 0.001), and lower cancer-specific mortality (p = 0.006) compared to patients with CKD stage ≤3. Multivariate Cox regression analysis revealed significant differences in intravesical recurrence (p = 0.014) and non-urothelial recurrence (p = 0.006) between the CKD stage >3 and CKD stage ≤3 groups. The study also demonstrated that patients with concurrent bladder cancer and variant histology had higher rates of intravesical recurrence, non-urothelial recurrence, and cancer-specific mortality. The CKD stage >3 group exhibited lower rates of intravesical recurrence (p = 0.0014), higher rates of non-urothelial recurrence (p < 0.0001), and increased cancer-specific mortality (p = 0.0091) compared to the CKD stage ≤3 group in the 5-year free survival analysis. ConclusionIn Taiwan, UTUC patients with CKD stage >3 exhibit distinct characteristics compared to the general population with urothelial carcinoma. They are associated with a non-smoking status, a higher proportion of females, and less aggressive pathological features. Additionally, CKD stage >3 can serve as a clinical indicator for intravesical and non-urothelial recurrence. Further investigation into molecular aspects and treatment modifications for these patients is warranted.

Renal Function Parameters in Distinctive Molecular Subtypes of Prostate Cancer.

Prostate cancer is a prevalent malignancy in male patients, having diverse clinical outcomes. The follow-up of patients diagnosed with prostate cancer involves the evaluation of renal function, because its impairment reduces patient survival rates and adds complexity to their treatment and clinical care. This study aimed to investigate the relationship between renal function parameters and distinctive molecular subtypes of prostate adenocarcinomas, defined by the immunoexpression of the SPINK1, ERG, HOXB13, and TFF3 markers. The study group comprised 72 patients with prostate cancer and associated chronic kidney disease (CKD) who underwent radical prostatectomy. Histopathological, molecular, and renal parameters were analyzed. Patients were categorized based on ERG/SPINK1 and HOXB13/TFF3 status, and correlations with renal function and prognostic grade groups were assessed. The ERG+/SPINK1+ subgroup exhibited significantly higher postoperative CKD stages and serum creatinine levels compared to the ERG+/SPINK1- subgroup. This suggests an intricate relationship between SPINK1 overexpression and renal function dynamics. The HOXB13-/TFF3+ subgroup displayed higher preoperative serum creatinine levels and CKD stages than the HOXB13-/TFF3- subgroup, aligning with TFF3's potential role in renal function. Furthermore, the study revealed associations between CKD stages and prognostic grade groups in different molecular subtypes, pointing out an intricate interplay between renal function and tumor behavior. Although the molecular classification of prostate acinar ADK is not yet implemented, this research underscores the variability of renal function parameters in different molecular subtypes, offering potential insights into patient prognosis.

Association of Baseline Chronic Kidney Disease Stage With Short- and Long-Term Outcomes After Fenestrated Endovascular Aneurysm Repair

Fenestrated endovascular aneurysm repair (FEVAR) is a well-established treatment approach for juxtarenal and short-neck infrarenal aortic aneurysms. Recommendations and clinical outcomes are lacking for offering FEVAR in patients with chronic kidney disease (CKD). We aimed to compare short- and long-term outcomes for patients with none-to-mild versus moderate-to-severe CKD undergoing FEVAR. We retrospectively reviewed consecutive patients undergoing standard FEVAR with Cook devices at a single institution. The cohort was stratified by preoperative CKD stage none-to-mild or moderate-to-severe (CKD 1-2 and CKD 3-5, respectively). The primary outcome was postoperative acute kidney injury (AKI). Secondary outcomes included 30-day perioperative complications, 1- and 5-year rates of overall survival, dialysis, renal target artery patency, endoleak, and reintervention assessed by the Kaplan-Meier method. Aneurysm sac regression, number of surveillance computed tomography (CT) scans, and CKD stage progression were assessed at latest follow-up. Multivariate Cox proportional hazards modeling was used to evaluate the association of CKD stage 3 and stage 4-5 with all-cause mortality, controlling for differences in baseline characteristics. From 2012- to 2022, 184 patients (of which 82% were male) underwent FEVAR with the Cook ZFEN device (mean follow-up 34.3months). Group CKD 3-5 comprised 77 patients (42%), was older (75.2 vs. 73.0years, P=0.04), had increased preoperative creatinine (1.6 vs. 0.9mg/dL, P<0.01), and demonstrated increased renal artery ostial calcification (37.7% vs. 21.5%, P=0.02) compared with Group CKD 1-2. Perioperatively, CKD 3-5 sustained higher estimated blood loss (342 vs. 228ml, P=0.01), longer operative times (186 vs. 162min, P=0.04), and longer length of stay (3 vs. 2days, P<0.01). Kaplan-Meier 1- and 5-year survival estimates were lower for CKD 3-5 (82.3% vs. 95.1%, P<0.01 and 55.4% vs. 70.8%, P=0.02). Fewer CKD 3-5 patients remained free from chronic dialysis at 1year (94.4% vs. 100%, P=0.015) and 5years (84.7% vs. 100%, P<0.01). There were no significant differences in postoperative AKI rate (CKD 1-2 6.5% vs. CKD 3-5 14.3%, P=0.13), long-term renal artery patency, reinterventions, type I or III endoleak, mean sac regression, or total follow-up CT scansbetween groups. CKD stage progression occurred in 47 patients (31%) at latest follow-up but did not differ between stratified groups (P=0.17). On multivariable modeling, age (hazardratio 1.05, 95% confidence interval 1.01-1.09, P=0.02) and CKD stage 4-5 (hazard ratio 6.39, 95% confidence interval 2.26-18.05, P<0.01) were independently associated with mortality. Preoperative CKD status did not negatively impact the durability or technical success related to aneurysm outcomes after FEVAR. Worsening CKD stage was associated with lower 1- and 5-year overall survival and freedom from dialysis after FEVAR with no statistically significant differences in 30-day or long-term technical aneurysm outcomes.

Post-Operative and Mid-Term Renal Function Impairment Following Elective Fenestrated Endovascular Aortic Repair for Complex Aortic Aneurysms: Incidence and Risk Factors Analysis.

Background. The aim of this study was to assess the incidence of two post-operative acute kidney injury (AKI) stages according to the Risk, Injury, Failure, Loss of function, End-stage (RIFLE) criteria in patients undergoing fenestrated endovascular aortic repair (FEVAR) for complex aortic aneurysms. Furthermore, we analyzed predictors of post-operative AKI and mid-term renal function deterioration and mortality. Methods. We included all patients who underwent elective FEVAR for abdominal and thoracoabdominal aortic aneurysms between January 2014 and September 2021, independently from their preoperative renal function. We registered cases of post-operative acute kidney injury (AKI) both at risk (R-AKI) and injury stage (I-AKI) according to the RIFLE criteria. Estimated glomerular filtration rate (eGFR) was noted preoperatively, at the 48th post-operative hour, at the maximum post-operative peak, at discharge, and then during follow-up approximately every six months. Predictors of AKI were analyzed with univariate and multivariate logistic regression models. Predictors of mid-term chronic kidney disease (CKD) (stage ≥ 3) onset and mortality were analyzed using univariate and multivariate Cox proportional hazard models. Results. Forty-five patients were included in the present study. Mean age was 73.9 ± 6.1 years and 91% of patients were males. Thirteen patients (29%) presented with a preoperative CKD (stage ≥ 3). Post-operative I-AKI was detected in five patients (11.1%). The aneurysm diameter, thoracoabdominal aneurysms and chronic obstructive pulmonary disease were identified as predictors of AKI in univariate analysis (OR 1.05, 95% CI [1.005-1.20], p = 0.030; OR 6.25, 95% CI [1.03-43.97], p = 0.046; OR 7.43, 95% CI [1.20-53.36], p = 0.031; respectively), yet none of these factors were significative on multivariate analysis. Predictors of CKD onset (stage ≥3) during follow-up on multivariate analysis were age (HR 1.16, 95% CI [1.02-1.34], p = 0.023), post-operative I-AKI (HR 26.82, 95% CI [4.18-218.10], p < 0.001) and renal artery occlusion (HR 29.87, 95% CI [2.33-309.05], p = 0.013), while aortic-related reinterventions where not significantly associated with this outcome in univariate analysis (HR 0.66, 95% CI [0.07-2.77], p = 0.615). Mortality was influenced by preoperative CKD (stage ≥3) (HR 5.68, 95% CI [1.63-21.80], p = 0.006) and post-operative AKI (HR 11.60, 95% CI [1.70-97.51], p = 0.012). R-AKI did not represent a risk factor for CKD (stage ≥ 3) onset (HR 1.35, 95% CI [0.45-3.84], p = 0.569) or for mortality (HR 1.60, 95% CI [0.59-4.19], p = 0.339) during follow-up. Conclusions. In-hospital post-operative I-AKI represented the main major adverse event in our cohort, influencing CKD (≥ stage 3) onset and mortality during follow-up, which were not influenced by post-operative R-AKI and aortic-related reinterventions.

Evaluation of Renal Function Recovery After Holmium Laser Enucleation of the Prostate in Patients with Chronic Kidney Disease.

Introduction: Holmium laser enucleation of the prostate (HoLEP) has become a new surgical gold standard treatment for benign prostatic hyperplasia (BPH). It is known that untreated BPH can lead to bladder outlet obstruction (BOO). A positive correlation exists between BOO and chronic kidney disease (CKD), but stability or recovery of renal function after HoLEP remains unknown. We sought to describe changes in renal function after HoLEP in men with CKD. Methods: A retrospective study was conducted of patients who underwent HoLEP with glomerular filtration rates (GFRs) <60, CKD stages III to V. Pre- and postoperative GFRs were selected within 3 months before the operation and within 1 year postoperatively. The presence of an indwelling catheter, preoperative hydronephrosis, history of kidney stones, and prostate size were also reviewed. Data were analyzed in accordance with preoperative CKD stage. Results: Of the reviewed patients, 138 met inclusion criteria with CKD stages III to V. Each CKD group was without significant postoperative complications. There was a significant increase between pre- and postoperative GFR for patients in CKD stages III (n = 116) and IV (n = 17) (p < 0.0001 and p = 0.010, respectively). The mean increase between pre- and postoperative GFR for the CKD stages III and IV patients were 6.4 and 6.49, respectively. There was no correlation between presence of preoperative hydronephrosis, history of kidney stones, catheter dependency, nor prostate size on change in postoperative GFR (p > 0.05). Conclusion: These findings suggest that patients in CKD stages III or IV undergoing HoLEP experience an increase in GFR. It is noteworthy that there appears to be no decline in renal function postoperatively in any group. HoLEP represents an excellent surgical option for patients with preoperative CKD and may prevent further renal decline.

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

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

MP56-17 THE IMPACT OF BASELINE CHRONIC KIDNEY DISEASE ON LONG-TERM SURVIVALS OF PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP56-17 THE IMPACT OF BASELINE CHRONIC KIDNEY DISEASE ON LONG-TERM SURVIVALS OF PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS Alireza Ghoreifi, Reza Sari Motlagh, Takafumi Yanagisawa, Tatsushi Kawada, Inderbir Gill, Siamak Daneshmand, Hooman Djaladat, and Shahrokh F Shariat Alireza GhoreifiAlireza Ghoreifi More articles by this author , Reza Sari MotlaghReza Sari Motlagh More articles by this author , Takafumi YanagisawaTakafumi Yanagisawa More articles by this author , Tatsushi KawadaTatsushi Kawada More articles by this author , Inderbir GillInderbir Gill More articles by this author , Siamak DaneshmandSiamak Daneshmand More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , and Shahrokh F ShariatShahrokh F Shariat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003309.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) is a complex surgery with considerable short- and long-term renal and metabolic complications, especially among those with preoperative chronic kidney disease (CKD). The aim of this study is to evaluate the impact of baseline CKD on oncologic and overall survival of patients who underwent RC for bladder cancer. METHODS: PubMed, Web of Science, Cochrane Library, and Scopus databases were searched for articles published by September 2022 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. After quality and risk of bias assessments, eligible studies were included in the meta-analysis. The primary outcome was overall survival (OS) and secondary outcomes included cancer-specific survival (CSS) and metastasis-free survival (MFS) of patients with CKD ≥3 (estimated glomerular filtration rate (GFR) <60 mL/min) undergoing RC. In addition, subgroup meta-analyses were performed in patients with different pre-operative CKD stages. RESULTS: Seven articles with 6900 patients were included in this study. In terms of oncological outcomes, MFS was compromised in patients with higher CKD stage by a HR of 1.54 (95% CI 1.15–2.05). In the subgroup analyses, patients with CKD3b and those with CKD stages ˃2 had a significantly worse MFS (HR=2.94, p ˂ 0.0001 and HR=1.45, p=0.03, respectively) (Figure 1-A). Also, we found that higher CKD stage could reduce CSS (HR 2.09, 95% CI 1.43–3.05). In the subgroup analysis, all subgroup HRs suggest a decreased CSS, however, patients with CKD3b and CKD ˃2 had a significantly worse CSS (HR=3.94, p˂0.0001 and HR=1.88, p=0.007) (Figure 1-B). Additionally, we found that a higher CKD stage could reduce OS by a HR of 1.47 (95% CI 1.21–1.79). Subgroup analyses showed that patients with CKD3a and CKD3b as well as those with CKD4 had a significantly worse OS (HR=1.13, p=0.03; HR=2.13, p=0.08; and HR=1.71, p=0.002, respectively) (Figure 1-C). CONCLUSIONS: Overall and oncological survivals are compromised in patients with CKD undergoing radical cystectomy. This effect is more prominent in patients with higher CKD stages. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e781 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alireza Ghoreifi More articles by this author Reza Sari Motlagh More articles by this author Takafumi Yanagisawa More articles by this author Tatsushi Kawada More articles by this author Inderbir Gill More articles by this author Siamak Daneshmand More articles by this author Hooman Djaladat More articles by this author Shahrokh F Shariat More articles by this author Expand All Advertisement PDF downloadLoading ...

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

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

Real-world outcomes of patients with renal cell carcinoma, surgically treated at regional hospitals, based on a prospective long-term survey of the pre-robotic era

PurposeRenal cancer surgery is frequently performed in small regional hospitals in Japan. This study evaluated the outcomes of renal cancer surgery, comparing results from the pre-robotic surgery era with those obtained with robotic surgery.MethodsThis prospective cohort study was conducted on patients who underwent renal cancer surgery between 2008 and 2013 at 14 hospitals, comprising 13 regional hospitals and a university hospital, registered in the Tohoku Urological Evidence-Based Medicine Study Group. The patients’ backgrounds; perioperative data; annual postoperative renal function; and prognostic surveys, performed over a median follow-up period of 10 years were obtained.ResultsIn 930 surgical cases at the 14 registered hospitals, the 10-year recurrence-free survival rates of cT1a, cT1b, cT2, and cT3 were 0.9326, 0.8501, 0.5786, and 0.5101, respectively. Meanwhile, the 10-year overall survival rates were 0.9612, 0.8662, 0.7505, and 0.7209, respectively. Long-term observation in patients with cT1 showed that vessel involvement and high tumor grade were prognostic factors for recurrence. As a noteworthy fact, radical nephrectomy was performed in 53.3% of patients with cT1a at the regional hospitals. However, even in patients with preoperative chronic kidney disease stage 3, radical nephrectomy was not a prognostic factor of renal function. This indicates that compensatory mechanisms had been working for a long time in many patients who underwent radical nephrectomies without hypertension and preoperative proteinuria, which were predictors of end-stage renal disease.ConclusionBased on a prospective long-term survey of the pre-robotic era, our results suggested no difference of the survival outcomes between the university hospital and regional hospitals. Our study provides baseline data to evaluate the outcomes of renal cancer robotic surgery, performed at regional hospitals.

EDITORIAL COMMENT

The authors retrospectively evaluated 6319 patients with renal tumors from 1980 to 2018 of whom 56% were treated with radical nephrectomy (RN) and 44% with partial nephrectomy (PN). They utilized multivariable linear and competing risk Cox proportional hazards models for increase in chronic kidney disease (CKD) staging to determine if there was a significant interaction between type of operation and preoperative CKD stage. They reported 12 months eGFR calculations in 3046 (48%) of the patients. Of note, 2055 patients (33%) had significant preexisting CKD (eGFR<60), 3466 patients (54%) had hypertension, 843 patients (13%) were diabetic, and 3440 patients (54%) were former or current smokers.

Can Aortic and Renal Arteries Calcium Scores Be New Factors to Predict Post-Operative Renal Function After Nephron Sparing Surgery?

This study aims to investigate whether the calcification of renal arteries and aorta may be risk factors for developing chronic kidney disease (CKD) after Nephron sparing surgery (NSS). The patients that underwent either open or laparoscopic NSS from 2000 to 2019 in 4 different centers were retrospectively assessed. Of these patients, 328 had a non-contrast-enhanced computer tomography. Calcium scores of the renal arteries and abdominal aorta were measured in the non-contrast-enhanced images with the calcium score plugin (version 2.0) of Horos™. Univariate and multivariate logistic regression analysis was performed to determine significant risk factors for developing CKD at the last check-up. Roc curve analysis was performed to determine the optimal cut-off values of age and abdominal aorta calcium scores. A total of 302 patients, of which 52 (16,6%) with CKD and 252 (83,4%) without CKD at the last check-up, were included in the analysis. The mean warm ischemia duration was significantly higher in patients with CKD (18,79±6,72 vs 16,38±5,57 minutes, p=0,016). The mean size of the tumor diameter and the number of the patients with ≥stage T1b were higher in the group with CKD (p=0,024 and 0,005, respectively). The median calcium scores of the aorta and renal arteries were higher in the group with CKD (p<0,001 and p<0,001, respectively). In multivariate analysis, age >60 years (OR:3,65, p=0,022), calcium score of the aorta (OR:4,07, p=0,029), tumor diameter (OR:1,03, p=0,026) and pre-operative CKD stage (OR:10,13, p<0,001) found the be significant factors for predicting last check-up CKD. The calcium score of the aorta may be used as an additional risk factor to predict post-operative CKD risk after NSS with sensitivity over 80%.

Efficacy and Safety of Percutaneous Nephrolithotomy in Patients with Chronic Kidney Disease: Outcomes from a Tertiary Care Center.

Background: The management of renal stone disease in the presence of chronic kidney disease (CKD) is a challenging scenario, both in terms of surgical safety and perioperative outcomes. The aim of the present study is to study the efficacy, safety, and outcomes of percutaneous nephrolithotomy (PCNL) in patients with CKD. Materials and Methods: A prospective study was conducted including adult patients with renal stone disease and a creatinine clearance of <90 mL/min (Stage 2 CKD or more) who underwent PCNL. Pre- and postoperative serum creatinine and glomerular filtration rates (GFRs) were compared. Patients were divided into CKD Stages 1 to 5 having creatinine clearance >90 mL/min, 60 to 90 mL/min, 30 to 60 mL/min, 15 to 30 mL/min, and <15 mL/min, respectively. Based on up migration or down migration of CKD stages, patients were classified as improved, deteriorated, or stable. Perioperative complications and outcomes were also compared. Results: A total of 185 patients with CKD Stage ≤2 underwent PCNL. The mean age of the patients was 43.24 ± 14.32 years. The mean preoperative estimated glomerular filtration rate (eGFR) was 62.88 ± 23.42 mL/min/1.73 m2. Preoperative CKD stage distribution was as follows: Stage 2 to 121 (65.4%), Stage 3 to 34 (18.4%), Stage 4 to 24 (13%), and Stage 5 to 6 (3.2%). On last follow-up of patients, the mean creatinine was 1.07 ± 0.65 mg/dL and the mean eGFR was 82.75 ± 31.22 mL/min/1.73 m2. The median change in creatinine and mean change in GFR were 0.23 (0.16-0.27) g/dL and 19.87 ± 19.77 mL/min/1.73 m2, respectively. Improvement in kidney function with a stage down migration was seen in 115 cases (62.2%), slight improvement with no change in stage in 69 cases (37.3%), and deterioration of CKD stage was present in one case (0.5%). Conclusion: PCNL is associated with favorable functional outcomes in CKD patients including severe CKD (Stages 4 and 5). Improvement or stabilization of CKD stage was seen in 99.5% of patients post-PCNL.

Pre-surgical chronic kidney disease continues to drive outcomes in the modern era of minimally invasive renal surgery, despite advances in technology.

To assess the impact of preoperative chronic kidney disease (CKD) on perioperative morbidity and mortality in a contemporary cohort undergoing renal surgery in an era of increased prevalence of minimally invasive surgery and partial nephrectomy. The National Surgery Quality Improvement Program dataset was queried to identify patients undergoing radical nephrectomy (RN) or partial nephrectomy (PN) between 2010 and 2018. CKD staging was assigned based on creatinine clearance calculated using the Cockcroft-Gault formula. Multivariable logistic regression was performed to assess the effect of preoperative CKD stage on postoperative outcomes, including a composite variable encompassing multiple major complications. We analyzed 19,545 patients with CKD undergoing renal surgery. CKD stage ≥ 2 predicted an increase in major perioperative complications, OR 1.54 (95% CI 1.46-1.63); p < 0.01. The risk of perioperative morbidity increased linearly with increasing CKD stage. Patients with CKD stage > 2 also demonstrated increased 30-day mortality, OR 1.87 (95% CI 1.26-2.48); p < 0.01. Adjusting for surgery type, CKD staging predicted perioperative mortality in patients undergoing RN only, and perioperative morbidity in RN and PN. Here, we demonstrate a statistically significant increase in the risk of major postoperative complications following RN and PN with increasing CKD stage. Amongst patients undergoing RN, we also demonstrate increasing 30-day mortality with increasing CKD stage. Importantly, we highlight the ability of CKD staging to predict major perioperative outcomes with greater magnitude of effect than surgery type alone. Thus, we provide a model for translating CKD staging into operative risk amongst patients undergoing surgery for a renal mass.

MP42-14 UPSTAGING OF CHRONIC KIDNEY DISEASE AFTER PARTIAL AND RADICAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III (MP42)1 Sep 2021MP42-14 UPSTAGING OF CHRONIC KIDNEY DISEASE AFTER PARTIAL AND RADICAL NEPHRECTOMY Cameron Britton, Christine Lohse, Abhinav Khanna, Vidit Sharma, John Cheville, Stephen Boorjian, Bradley Leibovich, H. Robert Thompson, and Aaron Potretzke Cameron BrittonCameron Britton More articles by this author , Christine LohseChristine Lohse More articles by this author , Abhinav KhannaAbhinav Khanna More articles by this author , Vidit SharmaVidit Sharma More articles by this author , John ChevilleJohn Cheville More articles by this author , Stephen BoorjianStephen Boorjian More articles by this author , Bradley LeibovichBradley Leibovich More articles by this author , H. Robert ThompsonH. Robert Thompson More articles by this author , and Aaron PotretzkeAaron Potretzke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002063.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Partial nephrectomy (PN) is generally preferred over radical nephrectomy (RN) when technically feasible. Nephron-sparing surgery may be particularly important for patients with chronic kidney disease (CKD). There is sparse literature comparing the outcomes of PN and RN in patients with CKD. We aim to illustrate the degree of renal functional change between PN and RN based on baseline renal function. METHODS: Adults treated with PN or RN for unilateral, sporadic, solid renal masses between 1980 and 2018 were identified. Patients who underwent PN or RN for a solitary kidney, were on dialysis at the time of surgery, or had stage 5 CKD at the time of surgery were excluded. Outcomes included positive margins, 30-day complications, and postoperative renal function assessed by CKD upstaging and percent change in eGFR at 3 months and 1 year following surgery compared to preoperative eGFR. Comparisons of outcomes were evaluated using chi-square, Fisher exact, and Wilcoxon rank sum tests. RESULTS: Amongst a total of 6,912 patients, 2,751 (40%) underwent PN and 4,161 (60%) underwent RN; 70 (2.5%) PNs and 99 (2.4%) RNs resulted in positive surgical margins (p=0.7); 164 (6%) PNs and 209 (5%) RNs resulted in Clavien grade 3 or higher complications. There were 3,471 and 3,256 patients with a 3-month and 1-year postoperative eGFR available for analysis. The interactions between type of surgery and CKD stage in models to predict CKD upstaging and percent change in eGFR were statistically significant (p <0.001 for all), indicating that the association of type of surgery with these outcomes differed by baseline CKD stage; as such, associations of type of surgery with 3-month and 1-year CKD upstaging and percent change in eGFR were stratified by CKD stage (Table). CONCLUSIONS: Patients with preoperative CKD stages 1-3 who underwent PN had significantly less renal functional decline at 3-months and 1-year as assessed by CKD upstaging and percent change in eGFR when compared to patients who underwent RN. There was no significant difference in renal functional outcomes in patients with baseline CKD stage 4, possibly reflecting a selection bias. Patients with stage 3 CKD, in particular, should be counseled regarding the reduced risk of CKD progression with PN. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e777-e777 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cameron Britton More articles by this author Christine Lohse More articles by this author Abhinav Khanna More articles by this author Vidit Sharma More articles by this author John Cheville More articles by this author Stephen Boorjian More articles by this author Bradley Leibovich More articles by this author H. Robert Thompson More articles by this author Aaron Potretzke More articles by this author Expand All Advertisement PDF DownloadLoading ...

The Efficacy and Renal Protective Effect of Tolvaptan in Chronic Kidney Disease Patients after Open-Heart Surgery.

Purpose: Unlike loop diuretics, tolvaptan is reported to have a renal protective effect. The purpose of this study was to retrospectively assess the efficacy of tolvaptan administration in chronic kidney disease (CKD) patients following open-heart surgery.Methods: From February 2017 to August 2020, 75 patients with preoperative CKD stages IIIb–V were enrolled in this study and were divided into two groups: the control group (n = 30) and the tolvaptan group (n = 45). All patients routinely received conventional diuretics starting from postoperative day (POD) 1. Tolvaptan at 7.5–15 mg/day was administered if the patients had persistent fluid retention or poor response to conventional diuretics.Results: Tolvaptan administration was initiated at a mean of POD 2.9 ± 2.2, and the mean dosing period was 4.1 ± 3.0 days. The mean time to return to the preoperative body weight in the control and tolvaptan groups was similar. However, estimated glomerular filtration rate (eGFR) was significantly increased at the time when body weight reached the preoperative level and at discharge in the tolvaptan group than in the control group.Conclusion: This study demonstrated the renal protective effect of tolvaptan even in advanced CKD patients after open-heart surgery.

Predictors of long-term renal function after kidney surgery for patients with preoperative chronic kidney disease.

We evaluated the trajectory of estimated glomerular filtration rate (eGFR) after kidney surgery in patients with kidney cancer and chronic kidney disease (CKD). We identified 1204 consecutive patients in our institutional database with preoperative CKD undergoing partial or radical nephrectomy from 1998-2016. Postoperative eGFR was tracked, with patients censored when receiving dialysis or kidney transplantation. A multivariable mixed-effects models assessed associations between preoperative baseline patient and tumor characteristics, and longitudinal eGFR. The Kaplan-Meier method and multivariable Cox regression were used to estimate overall survival, cancer-specific survival, and cumulative incidence of dialysis. Preoperatively, 892 (74.1%), 271 (22.5%), and 41 (3.4%) patients had CKD stage 3a, 3b, and 4/5, respectively. There were 55 patients dialyzed and 355 deaths (99 from kidney cancer). Median followup was 8.1 years, with 25 781 postoperative eGFR measurements. Factors associated with decreasing eGFR postoperatively included radical nephrectomy, male gender, older age, increased body mass index (BMI), and cardiovascular risk factors. We observed a significant interaction effect between time from surgery and preoperative CKD stage: the eGFR of stage 3a patients improved, while stage ≥3b declined (p<0.001). The two-year and five-year cumulative incidence of dialysis was 1.8% (1.1-2.6%) and 3.1% (2.2-4.2%), respectively. The cumulative incidence of dialysis, with death as a competing event, significantly differed by preoperative CKD stage. Preoperative CKD stage ≥3b is independently associated with a higher risk of declining renal function, dialysis, and mortality. With careful selection, patients with preoperative CKD withstand kidney surgery with low rates of dialysis.

Chronic Kidney Disease After Partial Nephrectomy in Patients With Preoperative Inconspicuous Renal Function - Curiosity or Relevant Issue?

Chronic kidney disease (CKD) is a severe long-term complication after partial nephrectomy (PN). Clinical and scientific focus lies on patients with impaired renal function at the time of surgery. Little data is available on patients with normal preoperative renal function (NPRF). Patients who underwent PN with a preoperative estimated glomular filtration rate > 60 mL/min/1.73m2 were retrospectively examined at 8 European urologic centers. The occurrence of new onset CKD≥ stage III after surgery (sCKD) was defined as the primary endpoint. Group comparisons and risk correlations were determined. Based on this data, a risk stratification model for sCKD was developed. Of the 1315 patients with NPRF included, 249 (18.9%) developed sCKD after a median follow-up of 44 months (range, 6-255 months). Pair analysis and univariable regression revealed age, arterial hypertension, American Society of Anesthesiologists score, tumor stage, surgical approach, intraoperative blood loss, perioperative blood transfusions and preoperative CKD stage as predictors for sCKD development. Multivariate analysis confirmed perioperative blood transfusion (hazard ratio [HR], 2.96; P≤ .0001), age (≥ 55 years; HR, 2.60; P= .0002), tumor stage (> pT1; HR, 2.15; P= .025), and preoperative CKD stage (stage II vs. I; HR, 3.85; P≤ .0001) as independent risk factors. A model that stratified patient risk for new onset CKD was highly significant (P< .0001). Every fifth patient with NPRF developed sCKD following PN. Elderly patients with higher tumor stage and who require blood transfusion appear to be at increased risk. Based on our risk stratification, patients with≥ 2 risk factors are candidates for an early, nephrologic follow-up.

Intraoperative Division of Left Renal Vein has No Impact on The Fate of Renal Function After the Open Surgery for Para- and Juxtarenal Abdominal Aortic Aneurysm

Introduction - Left renal vein (LRV) division is occasionally imperative for better access to the suprarenal aorta during open surgery (OS) for pararenal and juxtarenal abdominal aortic aneurysm (P/JRAA). However, its impact on the postoperative renal function remains controversial. Prior studies referred to the impact on acute kidney injury (AKI), but they have rarely evaluated longer-term renal function. This study focused on a chronic renal decline (CRD) during follow-up. Methods - A retrospective review of our series of P/JRAA treated with OS from June 2007 to January 2017. Patients on hemodialysis at the time of surgery were excluded. Preoperative renal function was estimated using the chronic kidney disease (CKD) staging system. Postoperative AKI was defined by the RIFLE criteria (Risk, Injury, Failure, Loss of function, End-stage renal disease). CRD was defined as progression in CKD stage or estimated glomerular filtration rate (eGFR) decline of >20%. The impact of LRV division on the postoperative renal function was investigated by a time-to-event analysis. Results - Among 469 elective OS, 119 underwent repair for P/JRAA. Three patients with preoperative hemodialysis and 1 in-hospital deaths were excluded from the analysis. Consequently, 115 patients were enrolled. Preoperatively, 42 patients (36.5%) had CKD stage 3 (eGFR < 60 mL/min/1.73 m2). Eight patients (8.7%) were in stage 4 (eGFR < 30 mL/min/1.73 m2). Proximal clamping was supraceliac (5 patients), suprarenal (38 patients), and inter-renal (72 patients). The median renal ischemic time was 33 minutes. LRVs were divided in 27 patients (group D), and stayed intact in 88 patients (group I). There was no significant difference in patients’ backgrounds between the groups. Group D tended to require higher proximal clamping (P=0.087) and related to significantly longer operation time (P<0.001). However, the median renal ischemic time was not significantly different between the groups (P=0.916). AKI seemed more common in group D, but not significant (P=0.103). During a median renal function follow-up for 13.8 months (interquartile range, 1.9-36.4), CRD was observed in 5 patients of group D and 14 patients of group I (18.5% and 16.1%, respectively). One patient in group I required hemodialysis 5 years after surgery. Kaplan-Meier curves to compare the freedom from CRD showed no significant difference between the groups (P=0.805; log-rank test). Risk-adjusted comparison, matching preoperative CKD stage and proximal clamp sites, did not change these findings. Conclusion - LRV division had no significant impact on CRD for up to 2 years during follow-up. Our result supported the safety of LRV division in terms of the mid-term outcomes.

Validating the use of contrast-induced nephropathy prediction models in endovascular aneurysm repairs

BackgroundExisting risk prediction models for contrast-induced nephropathy (CIN) are based on studies for percutaneous coronary interventions, with none validated for use in vascular procedures. We aim to validate existing CIN prediction models in patients who underwent aortic endovascular aneurysm repair (EVAR). MethodsA retrospective review of 216 patients who underwent EVAR between January 2008 and December 2015 was undertaken. Incidence of acute kidney injuries at 24, 48, and 72 hours and at follow-up were evaluated. Of 12 CIN prediction models within the literature, 8 were suitable for validation in patients who underwent EVAR and validation was performed with C-statistics. ResultsThere were 216 EVARs performed within the study period. The mean patients age was 73 years and 162 (75%) were performed in an elective setting. Percentage of preoperative chronic kidney disease stages 1 to 5 were 16%, 42%, 31%, 6%, and 5%, respectively. The mean intraprocedure contrast volume used was 280 mL. Incidence of acute kidney injuries at 24, 48, and 72 hours and at follow-up were 8%, 12%, 11%, and 6%, respectively. Three percent of patients became dialysis dependent. Validation of the eight existing CIN predication models reveal area under curve C-statistics between 0.61 and 0.75 (P = .026 to P < .001). Five of the 8 had good discriminative ability (C-statistics of >0.70) and the CIN prediction models by Mehran and Tziakas had the highest C-statistics at 0.75 (P < .001). ConclusionsIn our study population, 8 of 12 CIN prediction models within the literature were validated for use in patients undergoing EVAR and five are useful in identifying patients at risk for CIN.