A comprehensive assessment of frailty status on surgical,functional and oncologic outcomes in patients treated with partial nephrectomy—A large,retrospective, single-center study

BackgroundPartial nephrectomy (PN) is a challenging procedure, which can be associated with severe complications. In consequence, the search for accurate and independent indicators of unfavorable surgical outcomes appears warranted. We aimed at evaluating the impact of frailty status on surgical, functional and oncologic outcomes in patients undergoing PN for renal cell carcinoma (RCC).MethodsA retrospective, single-center study including 1,282 patients treated with PN for clinically localized cT₁ RCC was performed. The modified Frailty Index (mFI) was used to assess preoperative frailty. Multivariable logistic, Poisson and linear regression analyses(MVA) tested the effect of frailty on complications, acute kidney injury(AKI), renal function decline after PN. Cumulative incidence and competing-risk analyses investigated survival outcomes.ResultsOf 1,282 patients, 220 (17%) were frail. Overall, 982 (76%) vs. 123 (9.6%) vs. 171 (13%) patients underwent open vs. laparoscopic vs. robot-assisted PN. Median follow-up was 66 (IQR: 35–107) months. At MVA, frailty status predicted increased risk of complications [Odds ratio (OR): 1.46, 95%CI 1.17–1.84; P < 0.001]. Moreover, frail patients were at higher risk of postoperative AKI (OR: 1.95, 95%CI 1.13–3.35; P = 0.01). In frail patients, renal function permanently decreased over time (P = 0.01) without any renal function plateau or improvement during the follow-up, which were instead observed in the nonfrail cohort. At competing-risks analyses, frailty status predicted higher risk of other-cause mortality [Hazard ratio (HR): 1.67, 95%CI 1.05–2.66; P = 0.02], but not of cancer-specific mortality (P = 0.3).ConclusionsFrailty status predicts higher risk of adverse surgical outcomes after PN. Moreover, greater renal function decline was observed in frail patients, compared with nonfrail patients. Finally, the risk of OCM significantly overcomes the risk of dying due to RCC in frail patients.     

Thermal ablation for small renal masses: Identifying the most appropriate tumor size cut-off for predicting perioperative and oncological outcomes

ObjectivesTo test TRIFECTA achievement [1) absence of CLAVIEN-DINDO ≥3 complications; 2) complete ablation; 3) absence of ≥30% decrease in eGFR] and local recurrence rates, according to tumor size, in patients treated with thermal ablation (TA: radiofrequency [RFA] and microwave ablation [MWA]) for small renal masses.MethodsRetrospective analysis (2008–2020) of 432 patients treated with TA (RFA: 162 vs. MWA: 270). Tumor size was evaluated as: 1) continuously coded variable (cm); 2) tumor size strata (0.1–2 vs. 2.1–3 vs. 3.1-4 vs. >4 cm). Multivariable logistic regression models and a minimum P-value approach were used for testing TRIFECTA achievement. Kaplan-Meier plots depicted local recurrence rates over time.ResultsOverall, 162 (37.5%) vs. 140 (32.4%) vs. 82 (19.0%) vs. 48 (11.1%) patients harboured, respectively, 0.1 to 2 vs. 2.1 to 3 vs. 3.1 to 4 vs. >4 cm tumors. In multivariable logistic regression models, increasing tumor size was associated with higher rates of no TRIFECTA achievement (OR:1.11; P< 0.001). Using a minimum P-value approach, an optimal tumor size cut-off of 3.2 cm was identified (P< 0.001). In multivariable logistic regression models, 3.1 to 4 cm tumors (OR:1.27; P< 0.001) and >4 cm tumors (OR:1.49; P< 0.001), but not 2.1 to 3 cm tumors (OR:1.05; P= 0.3) were associated with higher rates of no TRIFECTA achievement, relative to 0.1 to 2 cm tumors. The same results were observed in separate analyses of RFA vs. MWA patients. After a median (IQR) follow-up time of 22 (12–44) months, 8 (4.9%), 8 (5.7%), 11 (13.4%), and 5 (10.4%) local recurrences were observed in tumors sized 0.1 to 2 vs. 2.1 to 3 vs. 3.1 to 4 vs. >4 cm, respectively (P= 0.01).ConclusionA tumor size cut-off value of ≤3 cm is associated with higher rates of TRIFECTA achievement and lower rates of local recurrence over time in patients treated with TA for small renal masses.     

Risk factors of acute kidney injury in patients with Stanford type B aortic dissection involving the renal artery who underwent thoracic endovascular aortic repair

BackgroundAcute kidney injury (AKI) is one of the most common and serious complications in patients with type B aortic dissection (TBAD). This study aimed at investigating the incidence and risk factors of in-hospital AKI in TBAD patients involving the renal artery who underwent thoracic endovascular aortic repair (TEVAR) only.MethodsA total of 256 patients who were diagnosed as TBAD combined with renal artery involvement were included in this retrospective study. All patients were divided into the AKI group and the non-AKI group according to the KDIGO criteria. The risk factors for AKI were identified using a multivariate logistic regression model.ResultsA total of 256 patients were included in this study, and the incidence of AKI was 18% (46/256). Patients in the AKI group were more likely to have a higher proportion of the youth, a higher level of body mass index, and a shorter time from onset to admission. Multivariate logistic regression analysis revealed that the youth (age ≤40 years) (OR: 2.853, 95%CI: 1.061–7.668, p = .038) were prone to AKI, and lower estimated glomerular filtration rate (eGFR) (OR: 1.526, per 15-ml/min/1.73 m² decrease, 95%CI: 1.114–2.092; p = .009), higher diastolic blood pressure (DBP) (OR: 1.418, per 10-mmHg increase; 95%CI: 1.070–1.879; p = .015), and fasting blood glucose (FBG) ≥7 mmol/L on admission (OR: 2.592; 95%CI: 1.299–5.174; p = .007) were independent risk factors for AKI.ConclusionsHigher incidence of AKI had been perceived in this study, most of them were young and middle-aged patients. Renopreventive measures should be considered in those high-risk patients with younger age, lower eGFR, higher DBP, and higher FBG on admission.     

Is partial nephrectomy safe and effective in the setting of frail comorbid patients affected by renal cell carcinoma? Insights from the RECORD 2 multicentre prospective study

BackgroundTo investigate the perioperative and morbidity outcomes after partial nephrectomy (PN) in patients with short life expectancy (SLE) (≥95% 10-year expected mortality (10y-EM)), to assess the main predictors of outcomes in this population and to compare these results with those of a group at the opposite upper range with long LE (LLE, ≤5% 10y-EM) relying on a multicenter Italian prospective registry of kidney surgery (the RECORD 2 project).MethodsClinical data of 4,325 patients undergone kidney surgery were collected at 26 urological Italian Centers from 2013 to 2016. SLE was defined as a ≥95% 10y-EM (assessed using the age-adjusted Charlson comorbidity index [CCI]). A multivariable logistic regression for overall postoperative complications, acute kidney injury (AKI), positive surgical margins (SM) and ? estimated glomerular filtration rate (eGFR) ≥25% at 2 years from surgery was performed in patients with SLE including clinically relevant variables. Adjusted outcomes reported as mean (SD) of the 2 groups were generated using separate multivariable logistic regression models and compared.ResultsOverall, 559 patients with SLE were selected. Patients had an ASA score ≥3 in 58.4% of cases. A clinical T1a, T1b, and T2 stage was found in 412 (74.5%), 124 (22.4%), and 17 (3.1%) patients. The median PADUA score was 7 (6–8). Surgical and medical postoperative complication rates were registered in 14.8% and 6% cases. Postoperative AKI was reported in 27.3% cases, positive surgical margins (PSM) in 9.3% cases. In this subgroup of patients, ASA score, cerebrovascular disease, surgery in low volume centers, and open surgery were independent predictors of overall complications. ASA and PADUA scores, renal clamping, resection technique and lower eGFR at baseline were independent predictors of AKI. PADUA score, open approach and resection technique were independent predictors of PSM. Cardiovascular disease, hilar clamping, and resection technique were independent predictors of eGFR decrease >25% at 2 years from surgery.Patients with SLE were compared with those with LLE (n = 302). All analyzed parameters at baseline were significantly different among the groups with the exception of cancer laterality. After adjusting for several clinical variables, the SLE group had a significantly higher risk rate of adjusted overall postoperative complication rate compared to the LLE group (20.6% ± 0.36 vs. 9.9% ± 0.65, P < 0.0001), while the overall intraoperative complications (4.1% ±0.13 vs. 2.3% ± 0.23), overall postoperative major complications (3.8% ± 0.09 vs. 1.9% ± 0.14) adjusted AKI (24.2% ± 0.37 vs. 22.6% ± 0.92), positive surgical margins (8% ± 0.22 vs. 6.4% ± 0.49), and 2-year RF loss (13.4% ± 0.17 vs. 12.4% ± 0.74).ConclusionIn selected patients with SLE, PN is feasible with an acceptable safety profile that is overall comparable to patients with no LE limitations. While a robotic approach and surgery performed in high volume centers could reduce the risk of complications, an off-clamp approach and a SE surgical technique may decrease the risk of postoperative AKI and of longer term eGFR decrease.     

Hydroxyethyl starch and acute kidney injury in high-risk patients undergoing cardiac surgery: A prospective multicenter study

BackgroundHydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients admitted to intensive care unit (ICU) for medical indications. We conducted a cohort study to evaluate the renal safety of modern 6% HES solutions in high-risk patients having cardiac surgery.MethodIn this multicentre prospective cohort study, we recruited 261 consecutive patients at high-risk for developing cardiac surgery-associated AKI, based on a Cleveland score ≥ 4 points, from July to December 2017th in 14 hospitals in Spain and the United Kingdom. Multivariable logistic regression modeling and propensity-score matched-pairs analysis were used to determine the adjusted association between administration of HES and AKI.ResultsOf the cohort, 95 patients (36.4%) received 6% HES 130/0.4 either intraoperatively or postoperatively. Postoperative AKI occurred in 145 patients (55.5%). The unadjusted odds of AKI was significantly higher in the HES group, when compared to those not receiving HES (OR 2.22, 95% CI 1.30–3.80, p = 0.003). In multivariable logistic regression models, modern HES was not associated with significantly increased risk of AKI (adjusted OR 0.84, 95% CI 0.41–1.71, p = 0.63). In propensity score match-pairs analysis of 188 patients, the HES group experienced similar adjusted odds of AKI (OR 1.05, CI 95% 0.87–1.27, p = 0.57) and RRT (OR 1.06, CI 95% 0.92–1.22, p = 0.36).ConclusionsThe use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with an increased risk of AKI nor dialysis in this cohort of patients at elevated risk for developing AKI after cardiac surgery.     

Utilization of a three-dimensional printed kidney model for favorable TRIFECTA achievement in early experience of robot-assisted partial nephrectomy

BackgroundThis retrospective study aimed to investigate whether a three-dimensional (3D) model would improve the achievement of TRIFECTA, which was defined as the absence of perioperative complications and positive surgical margins and a warm ischemia time of <25 minutes, during robot-assisted partial nephrectomy (RAPN).MethodsPrior to RAPN, a 3D-square type kidney model was prepared and used for all RAPN procedures in patients with T1a renal cell carcinoma (RCC) treated at a single center between March 2016 and April 2019. All RAPN procedures were performed by a single surgeon.ResultsThe study included 50 patients, of whom 22, 24, and 4 had low-, intermediate-, and high-risk R.E.N.A.L Nephrometry scores, respectively. The TRIFECTA achievement rate was 86.0%, and transfusion or conversion to radical nephrectomy was not required in any of the patients. Only one Clavien-Dindo grade 3 complication was reported—a pseudoaneurysm that required embolism. The TRIFECTA achievement rate was independent of the R.E.N.A.L Nephrometry scores and the surgeon’s experience level (25 cases each of early and advanced experience).ConclusionsThe 3D model contributed to the achievement of TRIFECTA during RAPN performed by a less-experienced surgeon. These findings should be further evaluated in studies involving a larger number of cases and surgeons.     

Improved outcomes of renal injury following burn trauma

BackgroundAcute kidney injury (AKI) is common in major burn injuries and associated with increased mortality. With advances in surgical and critical care it is unclear if mortality in this population remains this high. This study aims to describe incidence and outcomes of patients admitted to intensive care (ICU) with a burn injury who develop AKI. We additionally sought to determine risk factors for developing AKI.MethodsA historical cohort study of patients admitted to ICU from 2010 to 2016 with major burn injury was conducted. Demographic, laboratory, and clinical information was collected. AKI was defined by Acute Kidney Injury Network (AKIN) classification. Multivariable logistic regression was used to model association between baseline risk factors and risk of AKI.ResultsOf the 151 patients included, 64 people developed AKI (42%) defined by stages 1–3 of AKIN criteria. The median TBSA was 20% (IQR 9–41). Renal replacement therapy was required in 18/64 (28%) who developed AKI. Multivariable logistic regression demonstrated association between AKI and the following variables: APACHE II score (OR 1.2, 95%CI 1.1–1.3, P = 0.001), age (OR 1.8 per 10-year increase, 95%CI: 1.2–2.5, P = 0.002) and log(TBSA). Fractional polynomial regression analysis demonstrates that the best functional form of TBSA was in the natural logarithm (OR 2.7, 95%CI: 1.5–4.7, p = 0.001). Compared to those without AKI, patients with AKI had longer duration of mechanical ventilation, (median 11 [IQR 6–19] vs. 4 [IQR 2–9] days), ICU stay (15 [IQR 9–22] vs. 6 [IQR 3–10] days), and increased mortality (14 of 64(22%) vs. 4 of 87(5%).ConclusionsAKI is common in patients with a major burn injury. However, mortality is lower than described in the literature, particularly for those who required renal replacement therapy.     

No difference in renal function outcomes for patients with oncocytoma managed with active surveillance vs. partial nephrectomy

ObjectivesTo investigate the difference in renal function outcomes for patients with oncocytomas undergoing active surveillance (AS) vs. partial nephrectomy (PN).MethodsWe reviewed our institutional database for patients with biopsy/surgically confirmed oncocytoma from 2000-2020. The primary outcome was to assess for differences in renal function outcomes in patients undergoing AS vs. PN. We fit two generalized estimating equation (GEE) with an interaction term between follow up time and management strategy to predict 1) mean eGFR for patients managed with AS and PN and 2) the probability of progression to CKD stage III or greater.ResultsWe identified 114 eligible patients, of which 32 were managed with AS. Median follow-up was 21 months vs. 44 months for PN vs. AS patients. AS patients tended to be older (median: 72 years vs. 65 years, P<0.001) and have lower baseline renal function (median: eGFR: 71 mL/min/1.73m² vs. 82 mL/min/1.73m², P<0.001) compared with PN patients. Renal mass size from baseline imaging was similar between patients undergoing PN vs. AS (2.8 cm vs. 2.9 cm, P=0.634). For patients undergoing PN vs. AS, there was not a significant difference in predicted longitudinal eGFR (-0.079, 95% CI -0.18-0.023, P=0.129) or predicted probability of progression to CKD stage III or greater (OR: 0.61, 95% CI: 0.16-2.33, P=0.47).ConclusionsIn our institutional dataset, patients undergoing AS or PN with an oncocytoma had similar long-term renal function outcomes. Given similar renal function outcomes in patients undergoing AS and PN, surgery should remain reserved for select patients with oncocytomas.     

Upstaging to pT3a disease in patients undergoing robotic partial nephrectomy for cT1 kidney cancer: Outcomes and predictors from a multi-institutional dataset

ObjectivesSurgically treated clinical T1 (cT1) kidney cancer has in general a good prognosis, but there is a risk of upstaging that can potentially jeopardize the oncological outcomes after partial nephrectomy (PN). Aim of this study is to analyze the outcomes of robot-assisted PN (RAPN) for cT1 kidney cancer upstaged to pT3a, and to identify predictors of upstaging.Material and methodsThe study cohort included 1,640 cT1 patients who underwent RAPN between 2005 and 2018 at 10 academic institutions. Multivariate logistic regression model was used to assess the predictors of upstaging. Kaplan-Meier curves and multivariable Cox regression analyses were used to evaluate recurrence-free survival and overall survival.ResultsOverall, 74 (4%) were upstaged cases (cT1/pT3a). Upstaged patients presented larger renal tumors (3.1 vs. 2.4 cm; P = 0.001), and higher R.E.N.A.L. score (8.0 vs. 6.0; P = 0.004). cT1/pT3a group had higher rate of intraoperative complications (5 vs. 1% P = 0.032), higher pathological tumor size (3.2 vs. 2.5 cm; P < 0.001), higher rate of Fuhrman grade ≥3 (32 vs. 17%; P = 0.002), and higher number of sarcomatoid differentiation (4 vs. 1%; P = 0.008). Chronic kidney disease (CKD) stage ≥3 (OR: 2.54; P < 0.014), and clinical tumor size (OR: 1.07; P < 0.001) were independent predictors of upstaging. cT1/pT3a group had worse 2-year (94% vs. 99%) recurrence-free survival (P < 0.001).ConclusionsUpstaging to pT3a in patients with cT1 renal mass undergoing RAPN represents an uncommon event, involving less than 5% of cases. Pathologic upstaging might translate into worse oncological outcomes, and therefore strict follow-up protocols should be applied in these cases.     

Clinical analysis of 1 371 patients with acute kidney injury after acute myocardial infarction

Objective To investigate the risk factors of acute kidney injury (AKI) in patients after acute myocardial infarction (AMI). Methods A total of 1 371 adult patients diagnosed AMI in the First People's Hospital of Changzhou from January 2008 to December 2012 were analyzed retrospectively. AKI was defined according to the 2012 KDIGO AKI criteria. Based on the occurrence of AKI, the patients were divided into AKI group and non-AKI group. According to the AKI timing, the patients were divided into subgroups including conservative treatment groups, coronary angiography(CAG) groups and coronary artery bypass grafting (CABG) groups, respectively. Related risk factors of AKI were analyzed by univariate and multivariate logistic regression. Results Of the 1 371 patients,410(29.9%) developed AKI. Compared to the non-AKI group, in-hospital mortality increased significantly in the AKI group (17.1% vs 3.9%, χ2=68.0, P＜0.001). Multifactor retrospective analysis showed that decreased baseline eGFR (OR=2.049, 95%CI: 1.246-3.370), increased fasting plasma glucose(FPG) (OR=1.070, 95%CI: 1.018-1.124), diuretics (OR=1.867, 95%CI: 1.220-2.856) and Killip class 4 status (OR=1.362, 95%CI: 1.059-3.170) were all independent risk factors of AKI, while increased DBP on admission was a protective factor (OR=0.986, 95%CI: 0.974-0.998) for the conservative management group. Decreased baseline eGFR (OR=2.371, 95%CI: 1.500-3.747), increased FPG(OR=1.009, 95%CI: 1.005-1.012), diuretics (OR=1.674, 95%CI: 1.042-2.690), intraoperative hypotension (OR=2.276, 95%CI: 1.324-3.575) and acute infection (OR=1.678, 95%CI: 1.023-2.754) were independent risk factors of AKI for the CAG group. Decreased baseline eGFR (OR=2.246, 95%CI:1.340-3.981), increased FPG (OR=1.059, 95%CI: 1.018-1.124), diuretics (OR=1.723, 95%CI: 1.122-2.650), and low cardiac output syndrome after operation (OR=2.331, 95%CI: 1.277-3.286) were independent risk factors of AKI for CABG group. Conclusions AKI is a common complication and associated with increased mortality after AMI. Decreased baseline renal function, increased FPG and diuretics were common independent risk factors of AKI after AMI.     

Incidence and mortality of acute kidney injury in coronary care unit: a retrospective study from a single center

Objective To evaluate the incidence and mortality of acute kidney injury (AKI) in coronary care unit (CCU), and to identify the risk factors of the incidence of AKI and the mortality of CCU patients. Methods A total of 414 patients in CCU from January 1, 2014 to June 1, 2015 at Zhongnan Hospital of Wuhan University were enrolled. Based on the KDIGO-AKI criteria, these patients were classified into two groups: NAKI group (patients without AKI) and AKI group. Clinical characteristics and laboratory data of two groups were compared. The risk factors of the incidence of AKI and the mortality of CCU patients was analyzed by logistic regression, and then the receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of these risk factors. Results (1) Among 414 patients, 136(32.9%) patients fulfilled the criteria for AKI, and 14.0% patients in AKI stage 1, 10.9% in AKI stage 2 and 8.0% in AKI stage 3. (2) The total CCU mortality was 15.0%. Mortality of AKI patients in the CCU was 33.3%, higher than 6.1% in patients without AKI (OR=7.735, 95%CI 4.215-14.196, P＜0.001). The mortality worsened with increasing severity of AKI (22.4% for AKI stage 1 group, 37.8% for AKI stage 2 group, 45.4% for AKI stage 3 group). (3) Anemia (OR=8.274, 95%CI 4.363-15.689), history of chronic illness (OR=2.582, 95%CI 1.400-4.760), APACHEⅡ scores (OR=1.813, 95%CI 1.739-1.895), male (OR=3.666, 95%CI 1.860-7.226) were the independent risk factors for AKI, while the normal mean arterial pressure (MAP) (OR=0.292, 95%CI 0.153-0.556) and normal estimated glomerular filtration rate (eGFR) (OR=0.166, 95%CI 0.090-0.306) are the protective factors for AKI (all P＜0.05). (4) AKI was the most powerful independent factor associated with the mortality of CCU patients (OR=7.050, 95%CI 2.970-16.735, P＜0.001). Other independent risk factors for CCU mortality included history of chronic illness, ejection fraction and APACHEⅡ≥15 scores (all P＜0.05), while the normal MAP and normal eGFR were the protective factors (all P＜0.05). (5) For predicting AKI, eGFR displayed an excellent areas under the ROC curve (AUC=0.815, P＜0.001), and for CCU mortality, APACHEⅡ scores had the highest overall correctness of prediction (AUC=0.757 P＜0.001). Conclusions CCU patients have high morbidity of AKI, which is the most powerful independent factor associated with the increased CCU mortality. The eGFR is the best predictor for AKI, and then through the evaluation of eGFR for CCU patients, we can evaluate high-risk groups, make early interventions and then improve the prognosis of CCU patients.     

External validation of the VENUSS prognostic model to predict recurrence after surgery in non-metastatic papillary renal cell carcinoma: A multi-institutional analysis

ObjectiveRecently, VENUSS (VEnous extension, NUclear Grade, Size, Stage), as a prognostic model, was defined to predict disease recurrence (DR) after curative surgery of non-metastatic papillary renal cell carcinoma (papRCC). This study aimed to validate the VENUSS prognostic model in a large multi-institutional European cohort of patients with histopathologically proven papRCC after curative surgery for non-metastatic disease.Patients and MethodsOverall, 980 patients undergoing partial or radical nephrectomy for sporadic, unilateral and non-metastatic papRCC between 1987 and 2020 were included from 7 European tertiary institutions. The primary outcome was the prediction of DR by VENUSS score and VENUSS risk groups. Chi-square, Kruskal-Wallis, Cox-regression and Kaplan-Meier survival analyses were used in statistical methods. The Concordance (C) Index was calculated to assess model's discriminatory power.ResultsThe median age was 64 (IQR:55–70) years and 82.6 % (n = 809) of patients were male. Median VENUSS score was 2 (IQR: 0–4), and 62.9 % (n = 617), 23.9 % (n = 234) and 13.2 % (n = 129) of patients was classified into low, intermediate and high risk according to the VENUSS model, respectively. At a median follow-up of 48 (IQR:23–88) months, the disease recurred in 6.6%, 18.8% and 63.8%, and the 5-year recurrence-free survival was 93.8%, 80.7% and 26.7% in low, intermediate and high-risk groups, respectively. (P < 0.001) Each increase in VENUSS score had 1.52-fold (95%CI:1.45–1.60, P < 0.001) DR risk. Compared with the VENUSS low risk, the intermediate risk had a 2.91-fold increased DR risk (95%CI:1.90–4.46, P < 0.001) and 17.9-fold (95%CI:12.25–26.25, P < 0.001) in high risk, while it was 6.07-fold greater in high risk vs. intermediate risk (95%CI:4.17–8.83, P < 0.001). The discrimination was 81.2% (95%CI:77.5%–84.8%) for the VENUSS score, and 78.6% (95%CI:74.8%–82.4%) for VENUSS risk groups, respectively. Both the VENUSS score and groups were well calibrated.ConclusionsThis contemporary multi-institutional European large dataset validated the use of VENUSS score and VENUSS risk groups on the prediction of DR after curative surgery in patients with non-metastatic papRCC. The VENUSS prognostic model can provide valuable information for patient counselling, follow-up and patient selection for adjuvant trials.     

Preoperative proteinuria may be a risk factor for postoperative acute kidney injury：a meta-analysis

ObjectiveTo investigate the relationship between preoperative proteinuria and postoperative acute kidney injury (AKI).MethodsWe performed a search on databases included PubMed, Embase, the Cochrane Library, and Web of Science, from December 2009 to September 2020. Data extracted from eligible studies were synthesized to calculate the odds ratio (OR) and 95% confidence interval (CI). A fixed or random effects model was applied to calculate the pooled OR based on heterogeneity through the included studies.ResultsThis meta-analysis of 11 observational studies included 203,987 participants, of whom 21,621 patients suffered from postoperative AKI and 182,366 patients did not suffer from postoperative AKI. The combined results demonstrated that preoperative proteinuria is an independent risk factor for postoperative AKI (adjusted OR = 1.65, 95%CI:1.44–1.89, p < 0.001). Subgroup analysis showed that both preoperative mild proteinuria (adjusted OR = 1.30, 95%CI:1.24–1.36, p < 0.001) and preoperative heavy proteinuria (adjusted OR = 1.93, 95%CI:1.65–2.27, p < 0.001) were independent risk factors for postoperative AKI. The heterogeneity was combined because its values were lower. Further subgroup analysis found that preoperative proteinuria measured using dipstick was an independent risk factor for postoperative AKI (adjusted OR = 1.48, 95%CI:1.37–1.60, p < 0.001). Finally, preoperative proteinuria was an independent risk factor for postoperative AKI in the non-cardiac surgery group (adjusted OR = 2.06, 95%CI:1.31–3.24, p = 0.002) and cardiac surgery group (adjusted OR = 1.69, 95%CI:1.39–2.06, p < 0.001)ConclusionPreoperative proteinuria is an independent risk factor for postoperative AKI and in instances when proteinuria is detected using dipsticks.     

Comparison of surgical outcomes and split renal function between laparoscopic and robot-assisted partial nephrectomy: a propensity score-matched analysis

Purpose

The objective of this study was to compare perioperative outcomes and total and split renal function between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN). Predictive risk factors of preservation of operated renal function were also assessed.

Methods

We retrospectively analyzed 173 patients who underwent LPN (n?=?84) or RAPN (n?=?89) between 2010 and 2020. After propensity score matching (1:1), perioperative outcomes and total and split renal function were assessed. Logistic regression analysis was used to evaluate predictive risk factors of preservation of operated renal function. Trifecta criteria were defined as negative surgical margins, warm ischemia time (WIT)?<?25 min, and no complications more than Clavien–Dindo grade II within 4 weeks after surgery. Split renal function was evaluated by mercaptoacetyltriglycine renal scan.

Results

After propensity score matching, 42 patients were allocated to each group. RAPN was associated with significantly shorter WIT (RAPN vs LPN: 12 vs 22 min; p?<?0.0001) and higher trifecta achievement rate (93.3 vs 64.2%; p?<?0.0001). Other perioperative outcomes and total and split renal function were not significantly different between LPN and RAPN. The R.E.N.A.L. nephrometry score (RNS) was a predictive risk factor of preservation of operated renal function in the multivariable logistic regression analysis (odds ratio 1.68, 95% confidence interval 1.29–2.20, p?<?0.0001).

Conclusions

RAPN improved WIT and trifecta achievement rate, but it did not improve the preservation of operated renal function, for which RNS was found to be a strong predictive risk factor.

     

Racial Differences in AKI Incidence Following Percutaneous Coronary Intervention

BackgroundUndergoing percutaneous coronary intervention (PCI) is a risk factor for AKI development, but few studies have quantified racial differences in AKI incidence after this procedure.MethodsWe examined the association of self-reported race (Black, White, or other) and baseline eGFR with AKI incidence among patients who underwent PCI at Duke University Medical Center between January 1, 2003, and December 31, 2013. We defined AKI as a 0.3 mg/dl absolute increase in serum creatinine within 48 hours, or ≥1.5-fold relative elevation within 7 days post-PCI from the reference value ascertained within 30 days before PCI.ResultsOf 9422 patients in the analytic cohort (median age 63 years; 33% female; 75% White, 20% Black, 5% other race), 9% developed AKI overall (14% of Black, 8% of White, 10% of others). After adjustment for demographics, socioeconomic status, comorbidities, predisposing medications, PCI indication, periprocedural AKI prophylaxis, and PCI procedural characteristics, Black race was associated with increased odds for incident AKI compared with White race (odds ratio [OR], 1.79; 95% confidence interval [95% CI], 1.48 to 2.15). Compared with Whites, odds for incident AKI were not significantly higher in other patients (OR, 1.30; 95% CI, 0.93 to 1.83). Low baseline eGFR was associated with graded, higher odds of AKI incidence (P value for trend <0.001); however, there was no interaction between race and baseline eGFR on odds for incident AKI (P value for interaction = 0.75).ConclusionsBlack patients had greater odds of developing AKI after PCI compared with White patients. Future investigations should identify factors, including multiple domains of social determinants, that predispose Black individuals to disparate AKI risk after PCI.     

Ability of the surgical Apgar score to predict acute kidney injury following radical cystectomy

PurposeAcute kidney injury (AKI) is a common complication after radical cystectomy (RC). Previous literature has shown that intraoperative hemodynamic instability measured via the surgical Apgar score is an independent predictor of major complications following RC. We sought to determine whether the surgical Apgar score is predictive of postoperative AKI.MethodsWe performed a retrospective review of RC patients at our institution from 2010 to 2017. Intraoperative hemodynamic instability was captured via the Apgar score based on the lowest intraoperative mean arterial blood pressure, lowest heart rate, and estimated blood loss. Patients were divided into 3 groups: high-risk (HR; Apgar ≤4), intermediate-risk (IR; Apgar score 5–6), and low-risk (LR; Apgar score ≥7). AKIs were graded according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. High grade AKIs were defined as KDIGO grade 2 or 3. Categorical variables were assessed using the Pearson Chi-Square test, quantitative with the Kruskal-Wallis test, and multivariable logistic regression to identify predictors of AKI and high grade AKIs within 30 days of RC.ResultsEight hundred and seventy-three patients were included with a median follow-up of 35 months. AKI within 30 days was observed in 28% of patients. Predictors of AKI within 30 days on adjusted analysis included IR (OR: 1.83, P = 0.002) and HR (OR: 3.53, P < 0.001) Apgar scores. IR (OR: 2.23, P = 0.007) and HR (OR: 4.87, P < 0.001) Apgar scores were also predictors of high-grade AKIs.ConclusionIntraoperative hemodynamic instability measured via the Apgar score can be predictive of AKI, which can guide individualized fluid management in the postoperative period.     

“Ride the Green Light”: Indocyanine Green–marked Off-clamp Robotic Partial Nephrectomy for Totally Endophytic Renal Masses

BackgroundComplexity of robot-assisted partial nephrectomy (RAPN) mostly depends on tumor size and location. Totally endophytic renal masses represent a surgical challenge in terms of both intraoperative identification and anatomical dissection.ObjectiveTo detail a novel technique for marking preoperatively endophytic renal tumors with transarterial superselective intrarenal mass delivery of indocyanine green (ICG)-lipiodol mixture, in order to enhance surgical margins control during purely off-clamp (OC) RAPN with the use of near-infrared fluorescence imaging.Design, setting, and participantsBetween June and July 2017, 10 consecutive patients with totally endophytic renal masses underwent preoperative ICG tumor marking immediately followed by RAPN.Surgical procedurePreoperative superselective transarterial delivery of a lipiodol-ICG mixture (1:2 volume ratio) into tertiary-order arterial branches feeding the renal mass prior to transperitoneal OC-RAPN.MeasurementsClinical data were prospectively collected in our institutional RAPN dataset. Perioperative, pathological, and functional outcomes of RAPN were assessed.Results and limitationsMedian tumor size was 3 cm (interquartile range 2.3–3.8). The median PADUA score was 10 (9–11). Angiographic procedure was successful in all patients. Median operative time was 75 min (65–85); median estimated blood loss was 250 ml (200–350). No conversion to on-clamp PN or radical nephrectomy was needed. All patients had uneventful perioperative course; median hospital stay was 3 d (2–3). At discharge, median hemoglobin (Hgb) and percent estimated glomerular filtration rate (eGFR) drop were 3.3 g/dl (2.1–3.3) and 11% (10–20%), respectively. Surgical margins were negative in all cases. One-year median ipsilateral renal volume and 1-yr eGFR percent decreases were 11.7% (6–20.9%) and 12.2% (5.3–13.7%), respectively.ConclusionsWe described a novel technique to simplify challenging RAPN based on ICG superselective transarterial tumor marking. Key benefits include quick intraoperative identification of the mass with improved visualization and real-time control of resection margins.Patient summaryRobot-assisted partial nephrectomy (RAPN) for totally endophytic renal masses is a technically demanding surgical procedure, sometimes requiring radical nephrectomy. This novel technique significantly simplified surgical complexity in our Institution. Further studies with larger cohorts are warranted to confirm whether this technique provides relevant intraoperative and functional advantages.     

Retrospective analysis on incidence and risk factors of early onset acute kidney injury after lung transplantation and its association with mortality

ObjectivesAcute kidney injury (AKI) is a common complication after lung transplantation (LTx) which is closely related to the poor prognosis of patients. We aimed to explore potential risk factors and outcomes associated with early post-operative AKI after LTx.MethodsA retrospective study was conducted in 136 patients who underwent LTx at our institution from 2017 to 2019. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline. Univariate and multivariate analyses were conducted to identify risk factors related to AKI. The primary outcome was the incidence of AKI after LTx. Secondary outcomes were associations between AKI and short-term clinical outcomes and mortality.ResultsOf the 136 patients analyzed, 110 developed AKI (80.9%). AKI was associated with higher baseline eGFR (odds ratio (OR) 1.01 (95% confidence interval (CI): 1.00–1.03)) and median tacrolimus (TAC) concentration (OR 1.15 (95% CI: 1.02–1.30)). Patients with AKI suffered longer mechanical ventilation days (p = .015) and ICU stay days (p = .011). AKI stage 2–3 patients had higher risk of 1-year mortality (HR 16.98 (95% CI: 2.25–128.45)) compared with no-AKI and stage 1 patients.ConclusionsOur results suggested early post-operative AKI may be associated with higher baseline eGFR and TAC concentrations. AKI stage 1 may have no influence on survival rate, whereas AKI stage 2–3 may be associated with increased mortality at 1-year.     

Off-clamp robot-assisted partial nephrectomy does not benefit short-term renal function: a matched cohort analysis

In the interest of renal functional preservation, partial nephrectomy has supplanted radical nephrectomy as the preferred treatment for T1 renal masses. This procedure usually involves the induction of renal warm ischemia by clamping the hilar vessels prior to tumor excision. Performing robot-assisted partial nephrectomy (RAPN) “off-clamp” can theoretically prevent renal functional loss associated with warm ischemia. We describe our institutional experience and compare perioperative and renal functional outcomes using a propensity score matched cohort. We conducted a retrospective comparison from a prospectively maintained database of all patients who underwent RAPN from 2009 to 2015. Of those patients, 143 underwent off-clamp RAPN. Fifty off-clamp RAPN patients were propensity score matched with fifty clamped RAPN patients based on renal function, tumor size, and R.E.N.A.L. nephrometry score. The cohorts were compared across demographics, operative information, perioperative outcomes, and renal functional outcomes. For all off-clamp RAPN patients, mean nephrometry score was 7.1, mean estimated blood loss (EBL) was 236.9 mL, perioperative complication rate was 7.7%, and mean decrease in estimated glomerular filtration rate (eGFR) was 7.1% at a median follow-up of 9.2 months. In the propensity score matched cohorts, off-clamp RAPN resulted in a shorter mean operative time (172.0 versus 196.0 min, p = 0.025) and a lower mean EBL (179.7 versus 283.2 mL, p = 0.046). A lower complication rate of 6.0% in the off-clamp group compared with 20.0% in the clamped group approached significance (p = 0.071). Mean preoperative eGFR was similar in both cohorts. Importantly, there was no significant difference in decrease in eGFR between the clamped cohort (9.8%) and off-clamp cohort (11.9%) at a median follow-up of 9.0 months (p = 0.620). Off-clamp RAPN did not result in improved renal functional preservation in our experience. Surprisingly, the off-clamp cohort experienced lower intraoperative blood loss, shorter operative times, and fewer complications.     

Impact of acute kidney injury on renal allograft survival

Background: Acute kidney injury (AKI) is one of the major determinants of graft survival in kidney transplantation (KTx). Renal Transplant recipients are more vulnerable to develop AKI than general population. AKI in the transplant recipient differs from community acquired, in terms of risk factors, etiology and outcome. Our aim was to study the incidence, risk factors, etiology, outcome and the impact of AKI on graft survival.

Methods: A retrospective analysis of 219 renal transplant recipients (both live and deceased donor) was done.

Results: AKI was observed in 112 (51.14%) recipients, with mean age of 41.5?±?11.2 years during follow-up of 43.2?±?12.5 months. Etiologies of AKI were infection (47.32%), rejection (26.78%), calcineurin inhibitor (CNI) toxicity (13.39%), and recurrence of native kidney disease (NKD) (4.46%). New Onset Diabetes After Transplant (NODAT) and deceased donor transplant were the significant risk factors for AKI. During follow-up 70.53% (p?=?.004) of AKI recipients progressed to chronic kidney disease (CKD) in contrast to only 11.21% (p?=?.342) of non AKI recipients. Risk factors for CKD were AKI within first year of transplant (HR: 7.32, 95%CI: 4.37–15.32, p?=?.007), multiple episodes of AKI (HR: 6.92, 95%CI: 3.92–9.63, p?=?.008), infection (HR: 3.62, 95%CI: 2.8–5.75, p?=?.03) and rejection (HR: 9.92 95%CI: 5.56–12.36, p?=?.001).

Conclusion: Renal transplant recipients have high risk for AKI and it hampers long-term graft survival.