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Impact of Acute Kidney Injury and Its Duration on Long-term Renal Function After Partial Nephrectomy.

ABSTRACT: BACKGROUND:The relationship between acute kidney injury (AKI) and long-term renal function is controversial. The influence of AKI duration on functional recovery after partial nephrectomy has never been investigated. OBJECTIVE:To investigate the association between AKI and renal function 1yr after partial nephrectomy, and whether this relationship is affected by the duration of AKI. DESIGN, SETTING, AND PARTICIPANTS:We analyzed the data of 1893 patients treated by partial nephrectomy for a single cT1 N0 M0 renal mass. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:We defined three outcomes of interest: (1) recovery of at least 90% of baseline function 1yr after partial nephrectomy, (2) percentage change of 1-yr renal function compared with baseline function, and (3) chronic kidney disease (CKD) upstaging. AKI was defined according to the RIFLE criteria and recorded up to the 7th postoperative day. The association between AKI and each endpoint of interest was examined using regression models after adjustment for common predictors of renal function. RESULTS AND LIMITATIONS:A total of 388 (20%) patients experienced AKI after surgery. The rate of patients recovering 90% of baseline function was lower in the AKI group (30% vs 61%), while the proportion of patients who had CKD upstaging was significantly higher (51% vs 23%; both p<0.0001). At multivariable analysis, AKI was associated with worse renal function 1yr after partial nephrectomy, regardless of the outcome of interest (all p<0.0001). Longer AKI increases the risk of functional deterioration, especially after the 3rd day of injury. The risk of CKD upstaging for an average patient who had 1-3 versus ?4 d of AKI was 46% (95% confidence interval [CI]: 40%, 52%) versus 67% (95% CI: 55%, 78%; absolute risk increase of 21%; 95% CI: 8%, 34%). CONCLUSIONS:AKI negatively affects long-term functional recovery after partial nephrectomy, and thus, modifiable factors associated with AKI should be identified and corrected preoperatively. The duration of injury is informative, and should be included in the assessment of AKI and in future studies addressing this topic. PATIENT SUMMARY:Proper functional recovery after partial nephrectomy is jeopardized by acute kidney injury (AKI). Inclusion of the dimension of time into classification systems for AKI may be beneficial for postoperative risk stratification.

SUBMITTER: Bravi CA

PROVIDER: S-EPMC7641193 | biostudies-literature | 2019 Sep

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:We aimed to develop a nomogram based on preprocedural features for early prediction of acute kidney injury (AKI) and to assess the prognosis in patients after radical and partial nephrectomy. METHODS:The study included a development cohort of 1111 patients who were treated between June 2012 and June 2017 and an additional validation cohort of 356 patients who were treated between July 2017 and June 2018. Stepwise regression and logistic regression analyses were used to evaluate the association between predictors and AKI. Incorporating all independent predictors, a nomogram for postoperative AKI was developed and externally validated. Patients were followed up for 5 years to assess renal function, acute kidney disease (AKD), chronic kidney disease (CKD), hospital readmission and mortality were key prognosis we focused on. RESULTS:After multivariate logistic regression, radical nephrectomy (odds ratio (OR)?=?3.57, p?<?0.001), aspirin (OR?=?1.79, p?=?0.008), systolic blood pressure (OR?=?1.41, p?=?0.004), triglyceride (OR?=?1.26, p?=?0.024), and alkaline phosphatase (OR?=?1.75, p?=?0.034) were independent risk factors for postoperative AKI, while albumin (OR?=?0.72, p?=?0.031) was a protective factor for postoperative AKI. Patients with a higher estimated glomerular filtration rate (eGFR) (60-90?ml/min/1.73?m2, OR?=?0.41, p?=?0.004; ? 90?ml/min/1.73?m2, OR?=?0.37, p?<?0.001) were less prone to AKI than those with a lower eGFR (<?15?ml/min/1.73?m2). These predictors were all included in the final nomogram. The area under the receiver operating characteristics curve for the model were 0.77 (p?<?0.001) in the development cohort and 0.72 (p?<?0.001) in the validation cohort. The incidence of AKD and CKD were 27.12 and 18.64% in AKI group, which were much higher than those in no AKI group (p?<?0.001). CONCLUSIONS:The nomogram had excellent predictive ability and might have significant clinical implications for the early detection of AKI in patients undergoing nephrectomy.

Project description:BackgroundOngoing efforts are focused on shortening ischemia intervals as much as possible during partial nephrectomy to preserve renal function. Off-clamp partial nephrectomy (off-PN) has been a common strategy for to avoid ischemia in small renal tumors. Although studies comparing the advantages between off-PN with conventional on-clamp partial nephrectomy (on-PN) have been reported, the impact on short- and especially long-term renal function of the two surgical methods has not been discussed seriously and remained unclear. Our purpose is to evaluate the impact on short- (within postoperative 3 months) and long-term (postoperative 6 months or longer) renal function of off-PN compared with that of on-PN.MethodsWe comprehensively searched databases, including PubMed, EMBASE, and the Cochrane Library, without restrictions on language or region. A systematic review and cumulative meta-analysis of the included studies were performed to assess the impact of the two techniques on short- and long-term renal function.ResultsA total of 23 retrospective studies and 2 prospective cohort studies were included. The pooled postoperative short-term decrease of estimated glomerular filtration rate (eGFR) was significantly less in the off-PN group (weighted mean difference [WMD]: 4.81 ml/min/1.73 m2; 95% confidence interval [CI]: 3.53 to 6.08; p <?0.00001). The short-term increase in creatinine (Cr) level in the on-PN group was also significant (WMD: -?0.05 mg/dl; 95%CI: -?0.09 to -?0.00; p =?0.04). Significant differences between groups was observed for the long-term change and percent (%) change of eGFR (p =?0.04 and p <?0.00001, respectively) but not for long-term Cr change (p =?0.40). The postoperative short-term eGFR and Cr levels, but not the postoperative long-term eGFR, differed significantly between the two groups. The pooled odds ratios for acute renal failure and postoperative progress to chronic kidney disease (stage?3) in the off-PN group were found to be 0.25 (p =?0.003) and 0.73 (p =?0.34), respectively, compared with the on-PN group.ConclusionsOff-PN exerts a positive impact on the short- and long-term renal function compared with conventional on-PN. Given the inherent limitations of our included studies, large-volume and well-designed RCTS with extensive follow up are needed to confirm and update the conclusion of this analysis.

Project description:ObjectiveTo compare long-term outcomes and peri-operative outcomes of image-guided ablation (IGA) and laparoscopic partial nephrectomy (LPN).Material and methodsThis is a retrospective cohort study of localised RCC (T1a/bN0M0) patients undergoing cryoablation (CRYO), radio-frequency ablation (RFA), or LPN at our institution from 2003 to 2016. Oncological outcomes were compared using Cox regression and log-rank analysis. eGFR changes were compared using Kruskal-Wallis and Wilcoxon-rank tests.ResultsA total of 296 (238 T1a, 58 T1b) consecutive patients were identified; 103, 100, and 93 patients underwent CRYO, RFA, and LPN, respectively. Median follow-up time was 75, 98, and 71 months, respectively. On univariate analysis, all oncological outcomes were comparable amongst CRYO, RFA, and LPN (p > 0.05). On multivariate analysis, T1a patients undergoing RFA had improved local recurrence-free survival (LRFS) (HR 0.002, 95% CI 0.00-0.11, p = 0.003) and metastasis-free survival (HR 0.002, 95% CI 0.00-0.52, p = 0.029) compared to LPN. In T1a and T1b patients combined, both CRYO (HR 0.07, 95% CI 0.01-0.73, p = 0.026) and RFA (HR 0.04, 95% CI 0.03-0.48, p = 0.011) had improved LRFS rates. Patients undergoing CRYO and RFA had a significantly smaller median decrease in eGFR post-operatively compared to LPN (T1a: p < 0.001; T1b: p = 0.047). Limitations include retrospective design and limited statistical power.ConclusionsIGA is potentially as good as LPN in oncological durability. IGA preserves kidney function significantly better than LPN. More studies with larger sample size should be performed to establish IGA as a first-line treatment alongside LPN.Key points• Ablative therapies are alternatives to partial nephrectomy for managing small renal cell carcinomas. • This study reports long-term outcomes of image-guided ablation versus partial nephrectomy. • Ablative therapies have comparable oncological durability and better renal function preservation compared to partial nephrectomy.

Project description:Although partial nephrectomy is the preferred treatment for many patients with early-stage kidney cancer, recent clinical trial data, which demonstrate better survival for patients treated with radical nephrectomy, have generated new uncertainty regarding the comparative effectiveness of these treatment options.To compare long-term survival after partial vs radical nephrectomy among a population-based patient cohort whose treatment reflects contemporary surgical practice.We performed a retrospective cohort study of Medicare beneficiaries with clinical stage T1a kidney cancer treated with partial or radical nephrectomy from 1992 through 2007. Using an instrumental variable approach to account for measured and unmeasured differences between treatment groups, we fit a 2-stage residual inclusion model to estimate the treatment effect of partial nephrectomy on long-term survival.Overall and kidney cancer-specific survival.Among 7138 Medicare beneficiaries with early-stage kidney cancer, we identified 1925 patients (27.0%) treated with partial nephrectomy and 5213 patients (73.0%) treated with radical nephrectomy. During a median follow-up of 62 months, 487 (25.3%) and 2164 (41.5%) patients died following partial or radical nephrectomy, respectively. Kidney cancer was the cause of death for 37 patients (1.9%) treated with partial nephrectomy, and 222 patients (4.3%) treated with radical nephrectomy. Patients treated with partial nephrectomy had a significantly lower risk of death (hazard ratio [HR], 0.54; 95% CI, 0.34-0.85). This corresponded with a predicted survival increase with partial nephrectomy of 5.6 (95% CI, 1.9-9.3), 11.8 (95% CI, 3.9-19.7), and 15.5 (95% CI, 5.0-26.0) percentage points at 2, 5, and 8 years posttreatment (P < .001). No difference was noted in kidney cancer-specific survival (HR, 0.82; 95% CI, 0.19-3.49).Among Medicare beneficiaries with early-stage kidney cancer who were candidates for either surgery, treatment with partial rather than radical nephrectomy was associated with improved survival.

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Impact of Acute Kidney Injury and Its Duration on Long-term Renal Function After Partial Nephrectomy.

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