Preoperative Chronic Kidney Disease Research Articles

Surgical Aortic Valve Replacement and Renal Dysfunction: From Acute Kidney Injury to Chronic Disease.

Background: Surgical aortic valve replacement (SAVR) is often complicated by acute kidney injury (AKI). Identifying patients at risk of AKI is important to start nephroprotective strategies or renal replacement therapy (RRT). This study investigated the incidence and risk factors of post-operative AKI in SAVR patients. Chronic kidney disease (CKD) developed in the post-cardiac-surgery follow-up period was also assessed. Methods: A total of 462 SAVR patients were retrospectively enrolled. The primary endpoint was the occurrence rate of AKI after surgery. Kidney recovery, during two planned outpatient clinic nephrological visits within 12 months after the surgery, was assessed. Results: A total of 76 patients experienced an AKI event. A Kaplan-Meier analysis revealed that subjects with CKD stage IV had a time to progression of 2.7 days, compared to patients with stages I-II, who were characterized by the slowest progression time, >11.2 days. A Cox regression indicated that CKD stages predicted a higher risk of AKI independently of other variables. During their ICU stay, 23 patients died, representing 5% of the population, most of them requiring RRT during their ICU stay. A severe CKD before the surgery was closely related to perioperative mortality. During the follow-up period, 21 patients with AKI worsened their CKD stage. Conclusions: AKI represents a common complication for SAVR patients in the early post-operative period, prolonging their ICU stay, with negative effects on survival, especially if RRT was required. Pre-operative CKD >3 stage is an independent risk factor for AKI in patients undergoing SAVR.

Moderate and Severe Chronic Kidney Disease Predict Greater 5-Year Mortality following Major Lower-Extremity Amputation

Severe Chronic Kidney Disease (CKD) predicts greater mortality after major lower extremity amputation (LEA), but it remains poorly understood whether patients with earlier stages of CKD share similar risk. We assessed long-term postoperative outcomes for patients with CKD in a retrospective chart review of 565 patients who underwent atraumatic major LEA at a large tertiary referral center from 2015 to 2021. We stratified patients by renal function and compared outcomes including survival. Preoperative CKD diagnosis was related to many patient characteristics, co-occurred with many comorbidities, and was associated with less follow-up and survival. Kaplan-Meier and Cox Regression analyses showed significantly worse 5-year survival for major LEA patients with mild, moderate, or severe CKD compared to major LEA patients with no history of CKD at the time of amputation (P < 0.001). Severe CKD independently predicted worse mortality at 1-year (odds ratio [OR] 2.91; P = 0.003) and 5-years (OR 3.08; P < 0.001). Moderate CKD independently predicted worse 5-year mortality (OR 2.66; P = 0.029). This study demonstrates that moderate and severe CKD predict greater long-term mortality following major LEA when controlling for numerous potential confounders. This finding raises questions about the underlying mechanism if causal and highlights an opportunity to improve outcomes with earlier recognition and optimization CKD preoperatively.

Preoperative Age and Its Impact on Long-Term Renal Functional Decline after Robotic-Assisted Partial Nephrectomy: Insights from a Tertiary Referral Center.

Background and Objectives: to investigate the impact of age on renal function deterioration after robotic-assisted partial nephrectomy (RAPN) focusing on a decline to moderate and severe forms of chronic kidney disease (CKD). Materials and Methods: This is a single center prospective analysis of patients who underwent RAPN. The outcomes include the development of de novo CKD-S 3a [estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2)] and de novo CKD-S 3b (eGFR < 45 mL/min/1.73/m2). Multivariable analysis (MVA) via Cox regression identified predictors for CKD-S 3a/b. Kaplan -Meier Analyses (KMA) were fitted for survival assessment. Multivariable linear regression was utilized to identify the predictors of last-eGFR. Results: Overall, 258 patients were analyzed [low age (<50) n = 40 (15.5%); intermediate age (50-70) n = 164 (63.5%); high age (>70) n = 54 (20.9%)] with a median follow-up of 31 (IQR 20-42) months. MVA revealed an increasing RENAL score [Hazard Ratio (HR) 1.32, p = 0.009], age 50-70 (HR 6.21, p = 0.01), age ≥ 70 (HR 10.81, p = 0.001), increasing BMI (HR 1.11, p < 0.001) and preoperative CKD 2 (HR 2.43, p = 0.014) are independent risk factors associated with an increased risk of CKD-S 3a; conversely, post-surgical acute kidney injury was not (p = 0.83). MVA for CKD-S 3b revealed an increasing RENAL score (HR 1.51, p = 0.013) and age ≥ 70 (HR 2.73, p = 0.046) are associated with an increased risk of CKD-S 3b. Linear regression analysis revealed increasing age (Coeff. -0.76, p < 0.001), increasing tumor size (Coeff. -0.31, p = 0.03), and increasing BMI (Coeff. -0.64, p = 0.004) are associated with decreasing eGFR at last follow-up. We compare the survival distribution of our cohort stratified by age elderly patients experienced worsened CKD-S 3a/b disease-free survival (p < 0.001; p < 0.001, respectively). Conclusions: Age is independently associated with a greater risk of significant and ongoing decline in kidney function following RAPN. Recognizing the impact of aging on renal function post-surgery can guide better management practices. Further investigations are required.

CO2 is the contrast media to choose in patients with initial Chronic Kidney Disease undergoing endovascular aneurysm repair to prevent further renal function deterioration.

Even low quantities of iodine contrast media (ICM) could be responsible for exacerbation of a chronic kidney disease (CKD). Aim of this study was to determine whether it is more reasonable to perform endovascular aneurysm repair (EVAR) procedures in patients with initial CKD using CO2 rather than ICM to prevent further kidney deterioration. A retrospective analysis was performed at our institution to identify patients with preoperative CKD at initial stage (class G3a-G3b according to KDOQI-KDIGO classification) who underwent either CO2-EVAR or ICM-EVAR. Primary endpoint was renal function evaluation; secondary endpoints were technical success, perioperative complications, hospital stay, and reinterventions and overall mortality at follow-up. Both CO2-EVAR and ICM-EVAR groups were composed of 21 patients. There were no differences in demographics, anatomy, and comorbidities, apart from worse ASA score in CO2-EVAR group (100% vs 57.1%, p = .001). Preoperative serum creatinine and glomerular filtration rates (GFR) were comparable (1.73 vs 1.6mg/dl, p = .082 and 39.71 vs 43.04mL/min/1.73m2, p = .935). At follow-up (16.7 ± 18.1 months), CO2-EVAR was not associated with significant changes in creatinine and GFR, whereas ICM-EVAR determined a significant increase in creatinine (1.6mg/dl vs 1.91mg/dl, p = .04) and decrease in GFR values (43 vs 37.9mL/min/1.73m2, p = .04), determining the need for dialysis in one patient. ICM seems to be a determining factor in worsening renal function; therefore, an effort should be made to standardize the use of CO2 as the contrast medium of choice in patients with initial renal insufficiency undergoing EVAR.

Results of the Italian Collaborators for Evar Registry on Acute Kidney Injury After Elective Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm.

To analyze the incidence and predictive factors of postoperative acute kidney injury (AKI) after elective standard endovascular aortic repair (EVAR) in a large recent, multicenter cohort. This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study. Between January 2018 and March 2021, only patients treated with elective standard EVAR for infrarenal non-infected abdominal aortic aneurysm were analyzed. Patients already on hemodialysis (HD) were excluded. AKI was defined as an increase in serum creatinine (sCr) ≥0.3 mg/dL within 48 hours or an increase in sCr to ≥1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume of <0.5 mL/kg/h for 6 hours. Primary outcomes of interest were AKI incidence at 30 days and freedom from HD at 1-year follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year. The final cohort analyzed 526 (29.8%). There were 489 (93%) males and 37 (7%) females: the median age was 76 years (interquartile range [IQR], 71-81). Chronic kidney disease (CKD) was present in 86 (16.3%) patients. Early mortality was observed in 8 (1.5%) patients, none was aorta-related. Complication rate was 17.1% (n=89). AKI was observed in 17 (3.2%). Renal replacement therapy was needed in 4 (0.8%). HD was transitory in 2 cases and definitive in 1. Binary logistic regression analysis identified CKD (odds ratio [OR]: 4.68, 95% confidence interval [CI]: 2.10-10.45, p<0.001), and the presence of renal artery stenosis (OR: 3.80, 95% CI: 1.35-10.66, p=0.011) to be associated with an increased risk of postoperative AKI. Estimated freedom from ARM was 94.9% at 1 year. Estimated freedom from HD rate at 1 year was 94%: This was significantly different between patients with preoperative CKD and those who did not have preoperative CKD (log-rank, p=0.042). AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative CKD is the most important predictor for postoperative AKI, which was not associated with the need for HD at 1-year follow-up but with a higher propensity of mortality. This "real world" experience confirm that EVAR performed with standard contrats agent protocol remains safe for acute kidney injury development. Therefore, only patients presenting with preoperative borderline or ascertained chronic kidney disease will take the most advantage from the use of carbon dioxide contrast.

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, metastasis, 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 distant metastasis (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 metastasis (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, metastasis, and cancer-specific mortality. The CKD stage >3 group exhibited lower rates of intravesical recurrence (p = 0.0014), higher rates of metastasis (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.

Abstract 17423: The Conundrum of Oxygen Delivery in Redo Cardiac Surgery: Prognostic Implications and Interactions With Major Predictors

Introduction: Nadir oxygen delivery index (DO2i) during cardiopulmonary bypass (CPB) is a known independent predictor of Acute Kidney Injury (AKI) after routine cardiac surgery. Little is known about its prognostic role in the setting of redo procedures. Hypothesis: To define if Nadir DO2i is predictive of renal malperfusion in redo setting. Secondary outcomes were cardiac morbidity (composite of intra-aortic balloon pump or extracorporeal membrane oxygenation, use of continuous high dose inotropic support for at least 24 hours or autopsy evidence of heart failure), stroke and hospital mortality. Methods: All 398 consecutive patients (mean age of 62.1 ± 12.2 years, octogenarians 5.6%, female sex 47.4%, diabetes 20.1%, chronic kidney disease 31.2%, urgent/emergent status 26.2%, third-time sternotomy 9.8%; EuroSCORE II 10.5±11.2%) referred for a redo procedure (January 2011-January 2021) to a single tertiary care, university affiliated center were analyzed. The reliability of NadirDO2i to predict AKI was ascertained with AUC. The best cut-off was determined with the Youden index. The odds to incur in any of the predetermined outcomes was investigated with binary logistic regression. Interaction with known predictors of AKI (preoperative anemia, preoperative chronic kidney disease, older age, emergency status, baseline pathology, EuroSCORE II, need for CPB before sternotomy, blood transfusion during cardiopulmonary bypass) was also investigated. Results: Acute Kidney Injury (any grade) developed in 41.2 % (Risk 17.5%, Injury 8.0%, Failure 15.7%); cardiac morbidity developed in 53.2%, perioperative stroke in 2.8%. In-hospital mortality averaged 17.1%. Best Nadir DO2i predictor of AKI-Failure was 274 ml/min/m2 (AUC 0.644; 68.9% and 60.6% sensitivity and specificity, respectively). Same cut-off predicted cardiac morbidity and hospital mortality (OR 2.200, 95%CI 1.462-3.311 p=0.0002, and OR 4.677, 95%CI 2.577-8.488 p&lt;0.0001, respectively). No interaction of Nadir DO2i emerged with predefined predictors. Conclusions: Nadir DO2i during cardiopulmonary bypass is independently associated with major postoperative morbidity and mortality in redo scenario and is not influenced by other nuances variables.

Perioperative and Survival Outcomes of Patients Treated With Robot-Assisted Partial Nephrectomy and Percutaneous Microwave Ablation for Small Renal Masses: A Single Center Experience

BackgroundRobot assisted partial nephrectomy (RAPN) and microwave ablation (MWA) are 2 of the most advanced techniques for the management of localized small renal masses. PurposeTo compare the perioperative, functional and oncological results of RAPN and MWA. Materials and MethodsData from 171 consecutive patients undergoing either RAPN or MWA for a localized small renal mass at a single academic center was retrospectively collected. Baseline features included patients’ demographics and masses’ characteristics. Procedures were compared in terms of perioperative outcomes and renal function variation Progression of a persistent lesion or local recurrence after a complete treatment defined local tumor progression. Descriptive statistics and survival analysis tested the association between predictors and local tumor progression. ResultsOf all, 109 and 62 patients underwent RAPN and MWA. Patients in the MWA group were older (P = .002) had higher Charlson Comorbidity Index (CCI) (P < .001) and higher frequency of preoperative chronic kidney disease (P < .001). MWA led to a shorter postoperative hospitalization time (P < .001) and lower incidence of medical complications (6.5% vs. 22.9%, P = .02) than RAPN. GFR decline was similar between groups both at discharge (P = .39) and at the time of last follow up (P = 1.00). A lower rate of secondary interventions (11.7% vs. 2.8%, P = .037) and a better disease-free survival (83.2% vs. 96.5%, P = .027) were reported after RAPN. Conversely, cancer specific and overall survival were comparable (P > .05). At univariate regression analysis, MWA was associated with local tumor progression (HR 3.46, P = .040). ConclusionMWA displayed a lower perioperative impact, while functional outcomes were similar after each intervention. RAPN resulted superior in terms of tumor eradication, but no difference was noted regarding cancer specific survival. Thus, MWA represents a valid alternative in frail patients, though less radical than RAPN.

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.

Preoperative chronic kidney disease and complications after pancreatoduodenectomy: a retrospective cohort study.

Chronic kidney disease is a prevalent condition in surgical patients. Possible associations with increased postoperative morbidity and mortality have not been clearly demonstrated in patients undergoing pancreatoduodenectomy. The aim of this study was to assess the risk of postoperative complications in patients with reduced kidney function undergoing pancreatoduodenectomy. All patients undergoing pancreatoduodenectomy at Karolinska University Hospital between 2008 and 2019 were retrospectively included. The variable of interest was chronic kidney disease, based on preoperative estimated glomerular filtration rate measurements. Unadjusted and adjusted logistic regression analyses were performed for standardized postoperative complications. A total of 971 patients were included in the study, of whom 92 (10%) had an estimated glomerular filtration rate < 60 mL/min/1.73m2 , equivalent to chronic kidney disease Stage 3a or worse. Patients with chronic kidney disease had a higher odds of longer hospital stay (adjusted odds ratio 1.58, 95% confidence interval 1.00-2.50) and postoperative weight increase (adjusted odds ratio 2.02, 1.14-3.56). A 10 unit increase of preoperative estimated glomerular filtration rate was associated to lower odds of intensive care unit admission (adjusted odds ratio 0.81, 0.69-0.95), delayed gastric emptying (adjusted odds ratio 0.90, 0.81-0.99), and post-operative pancreatic fistula (adjusted odds ratio 0.83, 0.74-0.94). Patients undergoing pancreatoduodenectomy with decreased preoperative kidney function are more likely to experience major postoperative complications, and also postoperative weight increase. Preoperative kidney function assessment is important in risk stratification before pancreatoduodenectomies.

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.

Results of the Italian Collaborators for EVAR (ICE) Registry on Acute Kidney Injury After Elective Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm

The aim of this study was to analyze the incidence and predictive factors of postoperative acute kidney injury (AKI) after elective standard endovascular aortic repair (EVAR) in a large recent, multicenter cohort. This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study. Between January 2018 and March 2021, only patients treated with elective standard EVAR for infrarenal noninfected abdominal aortic aneurysm were analyzed. Patients already on hemodialysis (HD) were excluded. AKI was defined as an increase in serum creatinine (SCr) ≥0.3 mg/dL within 48 hours or an increase in SCr to ≥1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume of <0.5 mL/kg/h for 6 hours. AKI severity stage was classified according to the Acute Kidney Injury Network (AKIN) criteria. Primary outcomes were AKI incidence at 30 days and freedom from HD at 1 year of follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year. We analyzed 526 patients (86.5%). There were 489 males (93%) and 37 females (7%): the median age was 76 years (interquartile range, 3-8 years). AKI was observed in 17 patients (3.2%): it was classified as AKIN stage 1 in 12 (2.3%), AKIN stage 2 in three (0.6%), and AKIN stage 3 in two (0.2%). Renal replacement therapy was needed in four (0.8%): HD in three (0.6%, transitory in 2), and continuous veno-venous hemofiltration in one (0.2%). Binary logistic regression analysis identified chronic kidney disease (odds ratio [OR] 4.68; 95% confidence interval [CI], 2.10-10.45; P < .001), and the presence of renal artery stenosis (OR, 3.80; 95% CI, 1.35-10.66; P = .011) to be associated with an increased risk of postoperative AKI. Freedom from ARM was 99.2% at 1 year. Both serum creatinine and estimated glomular filtration rate were significantly different in comparison with preoperative and postoperative level. Of the patients who developed AKI postoperatively, 15 (88.2%) did not require further renal replacement therapy at 1 year; only two patients (0.4%), who already required HD postoperatively, remained on renal replacement therapy by HD at 1 year. Mortality at 1 year was higher in patients who developed postoperative AKI (18.7% vs. 5%; OR, 5.63; P = .051). AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative chronic kidney disease is the most important predictor for postoperative AKI, which was not associated with the need of HD at 1-year follow-up but with a higher propensity of mortality.

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.

Chronic Kidney Disease Predicts Greater 5-Year Mortality Following Major Limb Amputation.

Severe chronic kidney disease (CKD) predicts greater mortality after major lower extremity amputation (MLEA), but it remains poorly understood whether this finding extends to patients with earlier stages of CKD. We assessed outcomes for patients with CKD in a retrospective chart review of all patients who underwent MLEA at a large tertiary referral center from 2015 to 2021. We stratified 398 patients by glomerular filtration rate (GFR) and conducted Chi-Square and survival analysis. Preoperative CKD diagnosis was associated with many comorbidities, less 1-year follow-up, and greater 1- and 5-year mortality. Kaplan-Meier analysis showed worse 5-year survival for patients with any stage of CKD (62%) compared to patients without CKD (81%; P < .001). Greater 5-year mortality was independently predicted by moderate CKD (hazard ratio (HR) 2.37, P = .02) as well as severe CKD (HR 2.09, P = .005). These findings demonstrate the importance of identifying and treating CKD early preoperatively.

Thoracoabdominal aortic aneurysm life-altering events following endovascular aortic repair in the Vascular Quality Initiative

ObjectiveEndovascular aortic aneurysm repair (EVAR) has lower rates of postoperative mortality and morbidity when compared with open repair. However, endovascular repair still carries the risk of postoperative dialysis, paralysis, and stroke. This study examined the rates of postoperative mortality and morbidity stratified by type of endovascular aortic aneurysm repair. MethodsAll patients who underwent EVAR in the Vascular Quality Initiative registry from January 2011 to May 2022 were identified. Patients were stratified by repair type: infrarenal EVAR, complex EVAR, thoracic endovascular aortic repair (TEVAR), extent I to III thoracoabdominal aortic aneurysm (TAAA) repair, or aortic arch repair. The primary outcome was postoperative thoracoabdominal aortic aneurysm life-altering events (TALE) across the different treatment groups. TALE was defined as a composite outcome of postoperative mortality, dialysis, paralysis, and/or stroke. Mixed effect logistic regression modeling was used to identify procedural and anatomic factors that were independently associated with TALE. ResultsA total of 52,592 EVARs, 3768 complex EVARs, 3899 TEVARs, 1139 extent I to III TAAA repairs, and 479 arch repairs were identified. TALE was observed in 1.2% of EVARs, 4.8% of complex EVARs, 6.0% of TEVARs, 10% of extent I to III TAAA repairs, and 14% of arch repairs. More proximal landing zone was associated with higher odds of TALE after complex EVAR (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-3.1; P = .008), TEVAR (OR, 2.2; 95% CI, 1.4-3.5; P = .001), and extent I to III TAAA repair (OR, 2.7; 95% CI, 1.5-4.9; P = .001). Aortic diameter >65 mm was associated with higher odds of TALE after infrarenal EVAR (OR, 1.8; 95% CI, 1.4-2.3; P < .001), complex EVAR (OR, 1.6; 95% CI, 1.1-2.3; P = .010), TEVAR (OR, 2.7; 95% CI, 2.0-3.8; P < .001), and arch repair (OR, 2.4; 95% CI, 1.3-4.4; P = .007). The use of parallel grafting technique (chimney/snorkel/periscope) during extent I to III TAAA repair was also associated with higher odds of TALE (OR, 1.8; 95% CI, 1.1-3.2; P = .032). Preoperative chronic kidney disease was also associated with higher odds of TALE after infrarenal EVAR (OR, 4.3; 95% CI, 3.0-5.7; P < .001), complex EVAR (OR, 5.2; 95% CI, 3.3-8.2; P < .001), TEVAR (OR, 4.5; 95% CI, 2.8-7.1; P < .001), and extent I to III TAAA repair (OR, 3.2; 95% CI, 1.6-6.7; P = .001). ConclusionsAlthough TALE was originally described for TAAA repairs, TALE may occur after complex EVAR, TEVAR, and arch repairs as well. Therefore, TALE and its component parts should be used to evaluate the efficacy of all aortic repairs and for preoperative counseling. Additionally, surgeons should be aware of anatomic and procedural characteristics that are associated with higher odds of TALE. The anticipated need for such interventions during aortic repair should be factored into preoperative risk assessment of patients.

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 ...

Surgery for rheumatic heart disease in the Northern Territory, Australia, 1997–2016: what have we gained?

BackgroundBetween 1964 and 1996, the 10-year survival of patients having valve replacement surgery for rheumatic heart disease (RHD) in the Northern Territory, Australia, was 68%. As medical care has evolved...