Preoperative Renal Impairment Research Articles

Effect of on-pump vs. off-pump coronary artery bypass grafting in patients with non-dialysis-dependent severe renal impairment: propensity-matched analysis from the UK registry dataset.

On-pump coronary artery bypass (ONCABG) grafting in patients with a pre-existing poor renal reserve is known to carry significant morbidity and mortality. There is limited controversial evidence on the benefit of off-pump coronary artery bypass (OPCABG) grafting in these high-risk groups of patients. We compared early clinical outcomes in propensity-matched cohorts of patients with non-dialysis-dependent pre-operative severe renal impairment undergoing OPCABG vs. ONCABG, captured in a large national registry dataset. All data for patients with a pre-operative creatinine clearance of less than 50 mL/min who underwent elective or urgent isolated OPCABG or ONCABG from 1996 to 2019 were extracted from the UK National Adult Cardiac Surgery Audit (NACSA) database. Propensity score matching was performed using 1:1 nearest neighbor matching without replacement using several baseline characteristics. We investigated the effect of ONCABG vs. OPCABG in the matched cohort using cluster-robust standard error regression. We identified 8,628 patients with severe renal impairment undergoing isolated CABG, of whom 1,142 (13.23%) underwent OPCABG during the study period. We compared 1,141 propensity-matched pairs of patients undergoing OPCABG vs. ONCABG. The median age of the matched population was 78 years in both groups, with no significant imbalance post-matching in the rest of the variables. There was no difference between OPCABG and ONCABG in in-hospital mortality rates, post-operative dialysis, and stroke rates. However, the return to theatre for bleeding or tamponade was higher in ONCABG vs. OPCABG (P > 0.02); however, OPCABG reduced the total length of stay in the hospital by 1 day (P = 0.008). After double adjustment in the matched population using cluster-robust standard regression, ONCABG did not increase mortality compared to OPCABG (OR, 1.05, P = 0.78), postoperative stroke (OR, 1.7, P = 0.12), and dialysis (OR, 0.7, P = 0.09); however, ONCABG was associated with an increased risk of bleeding (OR, 1.53, P = 0.03). In this propensity analysis of a large national registry dataset, we found no difference in early mortality and stroke in patients with pre-operative severe renal impairment undergoing OPCABG or ONCABG surgery; however, ONCABG was associated with an increased risk of return to theatre for bleeding and an increased length of hospital stay.

Intraoperative haemofiltration during on-pump cardiac surgery at Queen Alia Heart Institute

Background: Objective of the study was to determine the frequency, indications and benefits of utilizing haemofiltration during cardiopulmonary bypass in adult cardiac surgical patients. Methods: This is a prospective observational analysis of data of adult cardiac surgical patients presented for on-pump cardiac surgery in the period between September 2023 and December 2023 at Queen Alia Heart Institute. Data was collected using Google Forms online and was subsequently recorded on Excel sheaths. Patients were divided into two groups: the haemofiltration group and the non-haemofiltration group. Both groups were compared according to perioperative laboratory and clinical variables. Statistical analysis of results using Microsoft excel followed data collection. Ethical committee approval was obtained. Results: Data from 130 adult cardiac surgical patients (105 males and 25 females) enrolled in this analysis showed that haemofiltration was used in 25 patients (19.2%). The most frequent indication for intraoperative haemofiltration was haemodilution in 14 patients (56%). Blood transfusion was needed in 17 (68%) of patients who had haemofiltration and in 35 (33.4%) of patients who did not need haemofiltration. Patients from the haemofiltration group were extubated 5 hours earlier than patients from the non-haemofiltration group, as the duration of mechanical ventilation in the ICU was 17.9 hours in the haemofiltration group versus 24.9 hours in the non-haemofiltration group. The average overall hospital stay was 3 days less in the haemofiltration group. Conclusions: Haemofiltration during cardiopulmonary bypass main indications were severe haemodilution, hyperkalaemia and preoperative renal impairment. The use of haemofiltration during CPB was associated with earlier tracheal extubation and shorter hospital stay.

Incidence and risk factors of postoperative acute myocardial injury in noncardiac patients: A systematic review and meta-analysis.

Postoperative myocardial injury after noncardiac surgery is common and is associated with short- and long-term morbidity and mortality. However, the incidence and risk factors for postoperative acute myocardial injury (POAMI) are currently unknown due to inconsistent definitions. We systematically searched PubMed and Web of Science to identify studies that applied the change value of preoperative and postoperative cardiac troponins to define cardiac injury. We estimated the pooled incidence, risk factors, and 30-day and long-term mortality of POAMI in noncardiac patients. The study protocol was registered with PROSPERO, CRD42023401607. Ten cohorts containing 11,494 patients were included for analysis. The pooled incidence of POAMI was 20% (95% CI: 16% to 23%). Preoperative hypertension (OR: 1.47; 95% CI: 1.30 to 1.66), cardiac failure (OR: 2.63; 95% CI: 2.01 to 3.44), renal impairment (OR: 1.66; 95% CI: 1.48 to 1.86), diabetes (OR: 1.43; 95% CI: 1.27 to 1.61), and preoperative beta-blocker intake (OR: 1.65; 95% CI: 1.10 to 2.49) were the risk factors for POAMI. Age (mean difference: 2.08 years; 95% CI: -0.47 to 4.62), sex (male, OR: 1.16; 95% CI: 0.77 to 1.76), body mass index (mean difference: 0.35; 95% CI: -0.86 to 1.57), preoperative coronary artery disease (OR: 2.10; 95% CI: 0.85 to 5.21), stroke (OR: 0.90; 95% CI: 0.50 to 1.59) and preoperative statins intake (OR: 0.65; 95% CI: 0.21 to 2.02) were not associated with POAMI. Patients with POAMI had higher preoperative hsTnT levels (mean difference: 5.92 ng/L; 95% CI: 4.17 to 7.67) and lower preoperative hemoglobin levels (mean difference: -1.29 g/dL; 95% CI: -1.43 to -1.15) than patients without. Based on this meta-analysis, approximately 1 in 5 of noncardiac patients develop POAMI. However, the lack of a universally recognized definition for POAMI, which incorporates diverse cardiac biomarkers and patient groups, poses a challenge in accurately characterizing its incidence, risk factors, and clinical outcomes.

Impact of nephroureterectomy on postoperative renal function in upper tract urothelial carcinoma: A multicenter retrospective study.

To assess the impact of radical nephroureterectomy on postoperative renal function in patients with upper tract urothelial carcinoma (UTUC). We retrospectively evaluated 645 patients with UTUC treated with radical nephroureterectomy between January 2000 and May 2022. The primary outcome was the rate of postoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 . Secondary outcomes included the rate of eGFR decline, identification of factors related to eGFR decline, and the impact of comorbidities (diabetes or cardiovascular disease) on postoperative eGFR at 1 year. The median preoperative and postoperative eGFR levels were 55.6 and 43.3 mL/min/1.73 m2 , respectively. The rate of patients with preoperative and postoperative eGFR ≥60 mL/min/1.73 m2 was 40.9% and 9.0%, respectively. The median decline in eGFR after surgery was 25.1%. The presence of preoperative unilateral hydronephrosis and eGFR <60 mL/min/1.73 m2 was significantly associated with a low decline of postoperative eGFR and poor survival. The impact of the presence of comorbidities on postoperative eGFR at 1 year was significant (p < 0.001). Impaired renal function is prevalent in patients with UTUC. The rate of patients with postoperative eGFR ≥60 mL/min/1.73 m2 was 9.0%. The presence of preoperative renal impairment was significantly related to a low decline in postoperative eGFR and poor survival. The presence of comorbidities had a significant effect on eGFR decline 1 year after radical nephroureterectomy.

Extracorporeal Photopheresis Suppresses Transplant Fibrosis by Inducing Decorin Expression in Alveolar Macrophages.

Extracorporeal Photopheresis Suppresses Transplant Fibrosis by Inducing Decorin Expression in Alveolar Macrophages.

Use of Secondary Iliac Branch Devices after Previous Endovascular Abdominal and Thoraco-Abdominal Aortic Aneurysm Repair

To assess the safety and effectiveness of iliac branch devices (IBDs), as secondary procedure, for the treatment of type Ib endoleak or evolution of iliac artery disease after prior endovascular aortic repair (EVAR) for thoraco-abdominal (TAAAs) or abdominal aortic aneurysms (AAAs). A multicentre observational study of three European centres. The study included 75 patients (age 71 ± 9 years, 96% men) with previous EVAR (n= 64, 85%) or fenestrated or branched (FB) EVAR (n= 11, 15%). Overall, 88 IBDs were implanted to treat aneurysmal iliac artery evolution in 40 (53%) and type Ib endoleak in 35 (47%) cases, respectively. Thirteen (17%) patients received bilateral IBDs. Internal iliac artery (IIA) catheterisation was done through a transaxillary access (n= 82, 93%) or up and over (n= 6, 7%) technique. The primary endpoint was technical success. Secondary endpoints were 30 day major adverse event, early and long term freedom from re-intervention and target vessel instability. All procedures were technically successful (100%). During hospitalisation, there were four (5%) major adverse events and three (4%) early re-interventions, but no death, stroke, or damage to previous endografts. The median follow up was 47 (interquartile range 42) months, and the five year survival rate was 78 ± 6% with no aortic related death. Cox's regression analysis showed pre-operative renal function impairment (hazard ratio [HR] 3.4; 95% confidence interval [CI] 1.1 - 10.1; p= .033), and primary TAAA repair (HR 6.1; 95% CI 1.6-22.3; p= .006) as independent factors for long term mortality. Freedom from re-interventions was 85 ± 4% at five years with 11 (12%) cases (five endoleaks, four IBD thromboses, two stenoses). IIA instability was reported in three (3%) limbs and freedom from IIA instability was 95 ± 3% after 60 months. Secondary IBD after EVAR is a safe and effective procedure with high technical success and low complication rates. The technique of choice to revascularise the IIA seems not to affect early and follow up results. Long term durability of IBD repair is acceptable with low rates of IIA re-intervention.

Effect of decreased renal function on poor oncological outcome after radical cystectomy.

To evaluate the impact of preoperative renal impairment on the oncological outcomes of patients with urothelial carcinoma who underwent radical cystectomy. We retrospectively reviewed the medical records of patients with urothelial carcinoma who underwent radical cystectomy from 2004 to 2017. All patients who underwent preoperative 99mTc-diethylenetriaminepentaacetic acid renal scintigraphy (DTPA) were identified. We divided the patients into two groups according to their glomerular filtration rates (GFRs): GFR group 1, GFR≥90 mL/min/1.73 m²; GFR group 2, 60≤GFR<90 mL/min/1.73 m². We included 89 patients in GFR group 1 and 246 patients in GFR group 2 and compared the clinicopathological characteristics and oncological outcomes between the two groups. The mean time required for recurrence was 125.5±8.0 months in GFR group 1 and 85.7±7.4 months in GFR group 2 (p=0.030). The mean cancer-specific survival was 131.7±7.8 months in GFR group 1 and 95.5±6.9 months in GFR group 2 (p=0.051). The mean overall survival was 123.3±8.1 months in GFR group 1 and 79.5±6.6 months in GFR group 2 (p=0.004). Preoperative GFR values in the range of 60≤GFR<90 mL/min/1.73 m² are independent prognostic factors for poor recurrence-free survival, cancer-specific survival, and overall survival in patients after radical cystectomy compared with GFR values of ≥90 mL/min/1.73 m².

Determinants of Acute Kidney Injury in Children Undergoing Cardiopulmonary Bypass: Single-Center Experience in Saudi Arabia.

Introduction Cardiopulmonary bypass (CPB) is a machine used in open cardiac surgeries and has been linked to many complications, one of which is acute kidney injury (AKI). Also, the Kidney Disease Improving Global Outcomes (KDIGO) criteria are used to diagnose AKI in the pediatric population. The study aimed to investigatethe association between cardiopulmonary bypass duration and renal function impairment in pediatric patients who had cardiac surgery. Methods Thiswas an observational, cross-sectional study conducted at the King Abdulaziz Medical City, King Faisal Cardiac Center, the section of the Pediatric Cardiac Intensive Care Unit (PICU), Ministry of National Guard Health Affairs, from January 2016 to December 2019. Patients younger than 14 years old, those having a cardiac surgery where CPB was implemented, normal pre-operative kidney functions, and having a cardiac surgery longer than 60 minutes (min) were included. The exclusion criteria were patients known to have pre-operative renal impairment and patients with pre-operative hemodynamic instability or cardiac arrest. Demographics ofpre-operative, intra-operative, andpost-operativedatawere extracted, and Statistical Package for the Social Sciences (SPSS) version 25 (Armonk, NY: IBM Corp.) was used for analysis. For descriptive statistics, frequencies and percentages for qualitative data were examined, while mean and standard deviation (SD) or median and interquartile range (IQR) quantitativedata were used accordingly. Student's t-test,Mann-Whitney(median test), chi-square, or Fisher's exact tests were used for univariate analysis accordingly. Logistic regression analysis was used to determine significant predictors for developing AKI. A p-value of <0.05 would be considered significant. Results Of the 111 patients,87 patients were included in the analysis. The median age was six months, IQR two to 13 months, body mass index (BMI) mean of 13.8, and SD 3.6. There was similar sex distribution, male 47.1% vs. female 52.9%. There were no patients in Risk Adjustment for Congenital Heart Surgery (RACHS) who scored 5 or 6. The AKI prevalence was 31% (27/87) within three days after surgery. One patient had stage 2 AKI; the rest were mild. One patient (3.7%) died. The CPB time was significantly longer in patients who developed AKI 150 (104-202), vs. non-AKI 104(82-142) min, p=0.004. In the AKI group, the mean baseline (pre-operative) serum creatinine (sCr) was significantly lower, whereas, it was significantly higher at 24 hours (h), and 48 hpost-operation (p=0.001, 0.001, and 0.036, respectively). Additionally, the estimated Glomerular Filtration Rate (eGFR) was significantly higher in the AKI group at 24 h(p=0.007). In logistical regression analysis, CPB time (per minunit time) was a significant predictor for developing AKI, OR 1.015, p=0.011 as a measured outcome. However, only CPB time >180 minwas highly significant with OR 16.2, p=00.6 compared to CPB time 121-180 minOR 2.3, p=0.29 and CPB time 91-120 minOR 1.2, p=0.84. Conclusion Acute kidney injury is an expected complication of pediatric congenital heart surgery receiving CPB. Although in our single-center experience, CPB duration was a significant predictor for AKI; however, it is considered a mild complication that does not contribute significantly to short-term morbidity or mortality. A larger multicenter, national prospective data registryis recommended to explore long-term effects.

The clinical role of bacteremia and bacterial spread into the irrigation fluid during percutaneous nephrolithotomy: a prospective study.

Backflow of pathogens and endotoxins from the renal pelvis to the bloodstream is one supposed mechanism for infectious complications development after endourological stones surgery. The aim of this study is detecting to prove bacterial spread into irrigation fluid and bloodstream during percutaneous nephrolithotomy (PCNL) and to correlate these findings with clinical and microbiological parameters and infectious complications (IC). Bladder urine culture (BUC) was retrieved before PCNL; during the procedure, 2 blood samples (BC) and an irrigation fluid sample during fragmentation (SFUC) were collected for culture. Stone culture (SC) was also obtained. Patients were evaluated post-operatively for IC. Sixty-one patients were prospectively included. IC occurred in 15 patients (24.6%). SFUC was positive in 7/61 (11.5%); BC in 10/61 (16.4%). Among patients with positive BC; BUC, SFUC and SC were positive in 9 (90%), 6 (60%), and 8 (80%) cases, respectively. Out of 10 patients with positive BC, 4 developed post-operative IC. Pre-operative renal impairment (p = 0.04), intraoperative-evaluated stone residual (p = 0.02), BUC (p = 0.004), and SC (p = 0.008) were associated with IC. No correlation was found between bacterial spread in the irrigation fluid and blood and IC. We proved that bacteria can be detected into the irrigation fluid and blood during PCNL. This transient bacteremia appears to be unrelated to IC development.

EUROPEAN NORDIC APROTININ PATIENT REGISTRY (NAPAR) DATA FROM NORDIC COUNTRIES INDICATE HALVED 30-DAY MORTALITY RATE COMPARED WITH EUROSCORE II IN HIGH-RISK HEART SURGERY

<h3>Objective</h3> According to European Medicines Agency (EMA) the on-label indication for aprotinin is for patients undergoing isolated coronary artery bypass graft surgery (iCABG), who are at high risk of major blood loss. The objective of the study was to describe current on- and off-label use of aprotinin and associated safety endpoints, including mortality, in adult patients undergoing high risk cardiac surgery in Nordic countries. <h3>Design and Method</h3> Data were analysed from cardiac surgery centres in Finland, Norway and Sweden that were participating in the European Nordic aprotinin patient registry (NAPaR), which is a non-interventional, post-authorization safety study (PASS) executed at EMA's request. Ethical approval was given by responsible authorities at each Hospital and all patients agreed to partake. The treating doctors determined if patients were to be given aprotinin. <h3>Results</h3> Altogether 489 patients were given aprotinin between 2016 to 2020 and of those 72.8% were male and 9.8% >75 years old. 59 patients (12.1%, on-label) underwent iCABG and 430 (87.9%, off-label) another procedure, including a surgery for aortic dissection (n=81, 18.8%) and endocarditis (n=175, 35.8%). 437 patients (89.4%) were given the full Hammersmith regimen and 37.2% had experienced at least one earlier heart procedure. 14.9% of all patients were on dual antiplatelet treatment, which affected 72.9% of iCABG and 7.4% of non-iCABG patients. Preoperative renal impairment (creatinine clearance < 85 mL/min) affected 50.7% of patients and 51.7% of the procedures were urgent, 17.0% emergent and 4.9% salvage. Mean/median bypass time was 159/148 min (range 25-637 min). 0.6% of patients had anaphylactic reactions associated with aprotinin. Within 24 and 48 hours postoperatively, 2.5% (CI95%:1.1%-3.8%) and 4.9% (3.0%-6.8%) of patients were reoperated for bleeding, respectively. Rate of postoperative thromboembolic events, day 1 rise in creatinine >44 μmol/L and new dialysis for any reason was 4.7% (CI95%: 2.8%-6.6%), 17.0% (CI95%: 13.6%-20.3%) and 14.3% (11.2%-17.4%), respectively. In-hospital mortality and 30-day mortality was 4.9% (CI95%: 2.8%-6.9%) and 6.3% (CI95%: 3.7%-7.8%) in all patients versus mean EuroSCORE II (estimates 30-day mortality) 11.4% (CI95%: 8.4%-14.0%, p<0.01). 30-day mortality in patients undergoing surgery for aortic dissection and endocarditis was 6.2% (CI95%: 0.9%-11.4%) and 6.3% (CI95%: 2.7%-9.9%) versus mean EuroSCORE II 13.4% (CI95%: 6.1%-21.0%, p=0.11) and 14.5% (CI95%: 12.1%-16.8%, p=0.01), respectively. <h3>Conclusions</h3> In patients given aprotinin at high risk of death and bleeding undergoing cardiac surgery, mainly complex procedures, 30-day mortality was significantly lower, with approximately halved mortality rates compared with estimations by EuroSCORE II. NAPaR data from Nordic countries suggest a favourable safety profile of aprotinin in adult cardiac surgery.

MP56-01 RENAL FUNCTIONAL CHANGES AFTER CYSTECTOMY: WHO IMPROVES AND WHO DOES NOT?

You have accessJournal of UrologyCME1 May 2022MP56-01 RENAL FUNCTIONAL CHANGES AFTER CYSTECTOMY: WHO IMPROVES AND WHO DOES NOT? Benjamin Croll, Dattatraya Patil, Khushali Vashi, Mehrdad Alemozaffar, Viraj Master, Christopher Filson, Kenneth Ogan, Vikram Narayan, and Shreyas Joshi Benjamin CrollBenjamin Croll More articles by this author , Dattatraya PatilDattatraya Patil More articles by this author , Khushali VashiKhushali Vashi More articles by this author , Mehrdad AlemozaffarMehrdad Alemozaffar More articles by this author , Viraj MasterViraj Master More articles by this author , Christopher FilsonChristopher Filson More articles by this author , Kenneth OganKenneth Ogan More articles by this author , Vikram NarayanVikram Narayan More articles by this author , and Shreyas JoshiShreyas Joshi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002639.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A significant decline in renal function following radical cystectomy has been documented in numerous settings and with a variety of urinary diversions. Implications of poor post-operative renal function include the need for renal replacement therapy and exclusion from adjuvant therapies. In the present study, we seek to better characterize two groups of particular interest: those with pre-operative renal impairment (PORI) who improve post-operatively and those with normal renal function who subsequently develop chronic renal insufficiency after surgery. METHODS: A prospectively maintained, single-institutional database retrospectively identified 367 patients who underwent radical cystectomy between 2013 and 2021. Patients were stratified by the presence of PORI, defined as having Stage III CKD (CKD3) or worse (n=142, 38.7%). Variables included the presence of ureteral obstruction before surgery and within one year post-operatively, diabetes, neoadjuvant chemotherapy, age, and rates of major complications. RESULTS: Compared to those with PORI, those with better renal function had a lower incidence of diabetes (33.1% vs. 20.4%, p=0.007). Rates of major complications after cystectomy were not significantly different between those with PORI vs. normal renal function (15.5% vs. 13.8%, p=0.649). Of those with PORI, 21 (23.3%) experienced renal function improvement to GFR >59 mL/min/1.73 m2 at 12 months post-operatively. Of these improved patients, 12 (57.1%) initially presented with ureteral obstruction. Within the remaining 225 patients without PORI, 49 patients (36.3%) developed CKD3 at 12 months post-operatively. Among these patients with renal function decline, 16 (32.7%) had ureteral obstruction within one year after surgery. Presence of diabetes, age >70, history of neoadjuvant chemotherapy, and type of diversion were not significantly different between the above groups. CONCLUSIONS: While 36.3% of patients with normal pre-operative renal function experienced a decline to CKD3 at one year, 23.3% of patients with PORI had resolution of CKD3 at one year. Ureteral obstruction appears to play a significant role in changes in long-term renal function. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e971 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benjamin Croll More articles by this author Dattatraya Patil More articles by this author Khushali Vashi More articles by this author Mehrdad Alemozaffar More articles by this author Viraj Master More articles by this author Christopher Filson More articles by this author Kenneth Ogan More articles by this author Vikram Narayan More articles by this author Shreyas Joshi More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP24-20 ANALYSIS OF PREDICTORS OF sCKD PROGRESSION AFTER MINIMALLY-INVASIVE IMPERATIVE PARTIAL NEPHRECTOMY IN PATIENTS WITH PREOPERATIVE CKD STAGE 3A: RESULTS OF A MULTI-INSTITUTIONAL COLLABORATIVE SERIES

MP24-20 ANALYSIS OF PREDICTORS OF sCKD PROGRESSION AFTER MINIMALLY-INVASIVE IMPERATIVE PARTIAL NEPHRECTOMY IN PATIENTS WITH PREOPERATIVE CKD STAGE 3A: RESULTS OF A MULTI-INSTITUTIONAL COLLABORATIVE SERIES

Factors associated with renal function change after unilateral adrenalectomy in patients with primary aldosteronism.

Decreased glomerular filtration rate has been reported in patients with primary aldosteronism after unilateral adrenalectomy. Glomerular hyperfiltration has been assumed to mask the preoperative subtle renal impairment. In this study, we investigated predictors for decreased estimated glomerular filtration rate after adrenalectomy in patients with primary aldosteronism. From January 2006 through September 2018, 328 patients with confirmatory diagnoses of primary aldosteronism received unilateral laparoscopic adrenalectomy and subsequent follow-up for 12 months. We prospectively collected related parameters of the clinical outcomes and renal function to identify predictors of renal function impairment at 12 months after surgery. Patients were stratified into three groups by preoperative estimated glomerular filtration rate level: 144 (43.9%) with estimated glomerular filtration rate ≥90, 130 (39.6%) with estimated glomerular filtration rate within 60-89.9, and 54 (16.5%) with estimated glomerular filtration rate <60 mL/min/1.73 m2 . The estimated glomerular filtration rate decreased significantly at the 6th month and remained stable at the 12th month, postoperatively. Patients with estimated glomerular filtration rate ≥90 had better clinical outcome with 59.6% success rate (P = 0.006) among three groups. Multivariate logistic regression analysis indicated that preoperative estimated glomerular filtration rate (odds ratio 1.012, P = 0.02) and hypokalemia (odds ratio 2.018, P = 0.024) were associated with renal impairment at 12th month after adrenalectomy. Multivariate linear regression analysis revealed high preoperative estimated glomerular filtration rate (β = 0.261, P < 0.001), high preoperative systolic blood pressure (β = 0.168, P = 0.003), high level of microalbuminuria (β = 0.024, P = 0.001), and low level of serum potassium (β = -4.883, P = 0.007) were associated with estimated glomerular filtration rate percentage decline at 12th month after adrenalectomy. Estimated glomerular filtration rate declined significantly after adrenalectomy in patients with estimated glomerular filtration rate ≥90. The study provided important information to identify primary aldosteronism patients with higher risk of estimated glomerular filtration rate decline after adrenalectomy and might help to adopt early interventions to improve the outcomes.

Early Outcomes of Coronary Artery Bypass Grafting in Patients with Preoperative Renal Dysfunction

Background: Chronic kidney disease combined with coronary artery disease is a growing public health issue. Preoperative renal dysfunction is one of the major risk factors for perioperative morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). This study aimed to analyze the early clinical outcomes of CABG in patients with preoperative renal impairment.&#x0D; Methods: The study was conducted from July 2017 to July 2019. We included 100 patients who underwent CABG. Group A (n= 50) included patients with preoperative renal impairment and group B (n= 50) had patients with normal renal functions.&#x0D; Results: The mean age was 63.3±9.1 years in Group A and 57.1±8.5 years in Group B (P&lt;0.001). There were 35 males in Group A and 47 in Group B (P&lt;0.001). Blood transfusion was more in Group A (47 (94%) vs. 32 (64%) patients; P=0.001). There was no difference in mortality between both groups.&#x0D; Conclusion: Preoperative renal impairment in patients undergoing CABG is more common in elder females. Patients undergoing CABG with preoperative renal impairment could have a higher risk for blood transfusion.

Identifying risk factors for early neurological outcomes following thoracic endovascular aortic repair using the SUMMIT database.

The aim of this study was to assess risk factors for early neurological complications following thoracic endovascular aortic repair (TEVAR) for multiple thoracic aortic diseases using an aggregated dataset. The Study to Assess Outcomes After Endovascular Repair for Multiple Throacic Aortic Disease dataset included data from 6 studies evaluating Zenith thoracic endografts. Post hoc analysis identified early (30-day) neurological complications by TEVAR indication and corresponding risk factors. The study included 594 TEVAR patients (67% male; mean age 66 ± 15 years) with thoracic aortic aneurysm (n = 329), ulcer (n = 56), acute (n = 126) or non-acute (n = 33) type B aortic dissection (TBAD) or blunt injury (n = 50). Overall early stroke rate was 3.5% (n = 21). Overall early paraplegia and paraparesis rates were 1.3% (n = 8) and 2.5% (n = 15), respectively. Multivariable analysis identified acute TBAD [versus others, odds ratio (OR) = 3.47, 95% confidence internal (CI): 1.41-8.52) and longer procedural time (OR = 1.33, CI: 1.02-1.73) as early stroke risk factors. Risk factors for paraplegia or paraparesis included more endografts deployed (OR = 2.43, CI: 1.30-4.55), older age (OR = 1.05, CI: 1.01-1.10) and higher preoperative serum creatinine (OR = 1.31, CI: 1.05-1.64). Endografts landing proximal to the left subclavian artery (LSA) increased stroke rate (versus distal to the LSA; 6.8% vs 2.3%, P = 0.014). Intraoperative LSA revascularization was performed in 20.9% of patients with endografts proximal to the LSA; revascularization did not significantly alter stroke rate (8.1% with revascularization vs 6.4% without, P = 0.72). Acute TBAD and prolonged procedure time increased early stroke risk, while more endografts placed, age and preoperative renal impairment increased early paraplegia or paraparesis risk. For acute TBAD, endograft placement proximal to the LSA, but not LSA patency, increased stroke risk.

APROTININ USE IN HIGH-RISK CARDIAC SURGERY: RECENT INSIGHTS FROM THE BELGIAN APROTININ PATIENT REGISTRY

Introduction In 2007, the use of aprotinin was temporarily suspended following several publications raising serious safety concerns.(1.2.3) However, Canadian and European Health Authorities concluded that these studies suffered from major flaws and lifted the suspension in 2013.(4,5) The reintroduction of aprotinin in 2016 was accompanied by a mandatory registry [Nordic Aprotinin Patient Registry (NAPaR)] in order to monitor the pattern of use, the effect of risk minimization measures, and overall safety. Objective of this study was to analyse the use of aprotinin in Belgium. Methods NAPaR is a non-interventional Post-Authorisation Safety Study (PASS), endorsed by the Pharmacovigilance Risk Assessment Committee of the European Medicine Agency. Results Between October 2018 and August 2020, six Belgian NAPaR centers included 694 patients [median age 70 (range 13-90y); 62% male; median EuroSCORE II 4.6 (range 0.5-93.4)]. 25% of the patients had an EuroSCOREII > 10. 57% of the patients were under an active antiplatelet therapy and 17% were treated with novel oral anti-coagulants. Preoperative renal impairment was present in 2/3 of patients. Only 4% of the patients received aprotinin on-label, i.e. for isolated coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB). In 96% of the patients, aprotinin was used off-label, mainly for redo surgery (32%), CABG + valve surgery (29%), aortic surgery (20%) and multiple valve surgery (17%). One third of the procedures were urgent (23%) or emergent (9%). Median bypass time was 128min (range 13-600min). Median hospital stay was 11 days (range 3-151 days). Main reported indications for the use of aprotinin were active dual antiplatelet therapy (68% in iCABG), redo surgery (16%) and expected prolonged CPB time (55%). In 83% of the cases, aprotinin was administered at the Half Hammersmith dose (1 Mio KIU loading- and priming-dose + 250.000 KIU/h); most patients received the appropriate test dose (98%), none developed anaphylactic reactions. Median perioperative blood loss was 400ml (range 40 -10050 ml), 44% of the patients had RBC transfusion and 6% underwent reoperation for bleeding or tamponade. Overall mortality at discharge was 5%, i.e. within the range or lower than predicted by the EuroSCORE II. 2% of the patients had a postoperative stroke. Postoperative AKI as defined by a serum creatinine increase of 0,3mg/dL or more within 48 hours after surgery was present in 13% of cases. Most of these patients (76%) suffered from preoperative moderate or severe renal impairment including dialysis. Notably, in patients with postoperative AKI median CPB time was significantly higher than in patients without AKI: 172min (range 56-402) vs 125min (range 13-600min) (p Discussion In the Belgian centers, aprotinin was mainly used off-label and predominantly administered to older patients with significant comorbidities undergoing high-risk procedures. The observed safety outcomes are in line with published data within this high risk patient population. The data from the Belgian NAPaR suggest that aprotinin has an excellent safety profile in adult cardiac surgery.

Renal surgery for kidney cancer: is preoperative proteinuria a predictor of functional and survival outcomes after surgery? A systematic review of the literature.

Proteinuria is considered both a known marker for the severity of chronic kidney disease (CKD) and a robust predictor of future renal function and cardiovascular morbidity and mortality in a general population. The urological community has long overlooked proteinuria as a marker of renal function. Recently, the American Urological Association (AUA) clinical practice guideline addressed this issue and suggested introducing proteinuria assessment prior to kidney cancer surgery. The aim of this systematic review was to provide evidence of proteinuria as a predictor of renal function impairment and survival outcomes after kidney surgery for renal tumors. A systematic search was performed by using three search engines (PubMed, Embase®, and Web of Science) from January 2010 to November 2020. Study selection followed the PRISMA guidelines. After screening, ten articles and abstracts fully compatible with the PICOS were included in this systematic review. Overall, a total of 11,705 patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) were analyzed. When used as a binomial variable, proteinuria prior to surgery was detected from 10% to 33% of patients. Relying on both proteinuria and estimated glomerular filtration rate (eGFR) in the assessment of renal function yielded up to 33% higher rates of patients with preoperative renal impairment. Moreover, proteinuria increased the risk of long-term renal impairment after PN and RN as well as patients with preoperative proteinuria undergoing PN exhibited a greater risk of postoperative acute kidney injury (AKI). Among eligible studies, proteinuria was associated with diabetes, obesity, metabolic syndrome, hypertension and cardiovascular disease. Finally, proteinuria was an independent predictor of overall mortality, but not of cancer-specific mortality. Proteinuria yields a prognostic power beyond that provided by estimated glomerular filtration rate (eGFR) among patients undergoing renal cancer surgery, supporting its introduction in the preoperative assessment of renal function. However, well-designed multicenter prospective studies would be necessary to corroborate these results and provided urological community with high-grade recommendation for clinical practice.

Splanchnic occlusive disease predicts for spinal cord injury after open descending thoracic and thoracoabdominal aneurysm repair

ObjectiveIn the present study, we sought to discern the effects of splanchnic occlusive disease (SOD; renal, superior mesenteric, and/or celiac axis arteries) on spinal cord injury (SCI; paraparesis or paraplegia) and major adverse events (MAE) after descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair. MethodsPatients who had undergone DTA/TAAA repair at our institution were dichotomized according to the presence of SOD, which was investigated as a predictive factor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, tracheostomy, de novo dialysis, MAE, survival) endpoints. Risk adjustment used both propensity score matching and multivariable logistic regression. ResultsFrom July 1997 to October 2019, 888 patients had undergone DTA/TAAA repair, of whom 19 were excluded from our analysis for missing data. SOD was absent in 712 patients and present in 157 patients. The patients with SOD had presented with a greater incidence of preoperative renal impairment (61 [38.9%] vs 175 [24.6%]; P < .01) and peripheral arterial disease (60 [38.2%] vs 162 [22.8%]; P < .01] and decreased left ventricular ejection fraction (45%; interquartile range, 10%; vs 50%; interquartile range, 4%; P < .01). The etiology of aortic disease was more frequently dissection in the SOD group (56.1% vs 43.7%) and more frequently nondissecting aneurysm in the non-SOD group (56.3% vs 43.9%; P < .01). Patients without SOD had presented with aneurysms more cranially located (DTA, 34.0% vs 7.6%; extent I TAAA, 44.0% vs 7.6%). In contrast, patients with SOD had presented with aneurysms more caudally located (extent II TAAA, 36.9% vs 8.6%; extent III TAAA, 30.6% vs 11.0%; extent IV TAAA, 17.2% vs 2.5%; P < .01). Propensity score matching led to 144 pairs, with SOD significantly associated with SCI (10 [6.9%] vs 2 [1.4%]; P = .03) and MAE (47 [32.6%] vs 26 [15%]; P < .01). Ten-year survival was reduced in those with SOD (31.5% vs 45.2%; P < .01). Conditional multivariable regression confirmed SOD to be a predictor of SCI in the matched sample (odds ratio, 6.60; P = .02). ConclusionsOur results have shown that SOD is a significant predictor of SCI in patients undergoing open DTA/TAAA repair. The investigation of measures to prolong neuronal ischemia tolerance (eg, hypothermia) is warranted for such patients.

Impact of urgent coronary artery bypass grafting on acute kidney injury : Amatched cohort study.

There is limited knowledge regarding the specific interrelationships between urgent coronary artery bypass graft (U-CABG) surgery and postoperative acute kidney injury (AKI). We aimed to (1)analyze the impact of urgent CABG (U-CABG) on the incidence and severity of postoperative AKI, (2)estimate the influence of AKI after U‑CABG or elective CABG (E-CABG) on mortality and (3)identify risk factors for AKI depending on the urgency of operation. U‑CABG patients showed ahigher incidence of AKI (49.8% vs. E‑CABG: 39.7%; p = 0.026), especially for higher AKI stages 2 + 3. In-hospital mortality was higher in U‑CABG patients (12.6%) compared to E‑CABG patients (2.3%; p < 0.001). The impact of AKI on mortality did not differ, but showed astrong coherency between higher AKI stages (2 + 3) and mortality (stage1: OR 2.409, 95%CI 1.017-5.706; p = 0.046 vs. stage 2 + 3: OR 5.577; 95%CI 2.033-15.3; p = 0.001). Univariate logistic regression analysis revealed that preoperative renal impairment, peripheral vascular disease and transfusion of more than two red blood cell concentrates were predictors for postoperative AKI in both groups. U‑CABG is arisk factor for postoperative AKI and even "mild" AKI leads to asignificantly higher mortality. Hence, the prevention of modifiable risk factors might reduce the incidence of postoperative AKI and thus improve outcome.

Prognostic value of high-sensitivity troponin I after cardiac surgery according to preoperative renal function.

Cardiac troponin levels can be elevated without myocardial injury in patients with renal impairment. However, the prognostic value of elevated troponin levels after cardiac surgery has not been well evaluated in patients with renal impairment. We evaluated the relationship between postoperative troponin levels and mortality following cardiac surgery according to preoperative renal function.Among 3661 patients underwent cardiac surgery between March 2005 and December 2015, 1909 patients were analyzed after excluding those with insufficient laboratory data, preoperative myocardial infarction, underwent Cox-Maze or redo surgery, or with a follow-up period <30 days. The primary outcome was risk of 30-day mortality according to elevated postoperative high-sensitivity cardiac troponin I (hs-cTnI) levels in varying degrees of renal function. Secondary outcomes included long-term cardiac-cause and all-cause mortality during the median follow-up of 52 months.After adjustment for risk factors, elevated peak postoperative hs-cTnI was associated with 30-day mortality [adjusted odds ratio 1.028, 95% confidence interval (CI) 1.013-1.043, P < .001], long-term cardiac-cause [adjusted hazard ratio (HR) 1.013, 95% CI 1.009-1.017, P < .001] and all-cause mortality (adjusted HR 1.013, 95% CI 1.009-1.016, P < .001), in patients with preoperative normal renal function [estimated glomerular filtration rate (eGFR) ≥60 ml/minute/1.73 m]. However, in patients with renal impairment (eGFR < 60 ml/minute/1.73 m), hs-cTnI levels were not associated with mortality following cardiac surgery.Elevated hs-cTnI levels following cardiac surgery did not predict short- and long-term mortality in patients with preoperative renal impairment.