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No AccessJournal of UrologyAdult Urology1 Feb 2011

Comparison of Cold and Warm Ischemia During Partial Nephrectomy in 660 Solitary Kidneys Reveals Predominant Role of Nonmodifiable Factors in Determining Ultimate Renal Function

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    Purpose:

    Factors that determine renal function after partial nephrectomy are not well- defined, including the impact of cold vs warm ischemia, and the relative importance of modifiable and nonmodifiable factors. We studied these determinants in a large cohort of patients with a solitary functioning kidney undergoing partial nephrectomy.

    Materials and Methods:

    From 1980 to 2009, 660 partial nephrectomies were performed at 4 centers for tumor in a solitary functioning kidney under cold (300) or warm (360) ischemia. Data were collected in institutional review board approved registries and followup averaged 4.5 years. Preoperative and postoperative glomerular filtration rates were estimated via the Chronic Kidney Disease-Epidemiology Study equation.

    Results:

    At 3 months after partial nephrectomy median glomerular filtration rate decreased by equivalent amounts with cold or warm ischemia (21% vs 22%, respectively, p = 0.7), although median cold ischemic times were much longer (45 vs 22 minutes respectively, p <0.001). On multivariable analyses increasing age, larger tumor size, lower preoperative glomerular filtration rate and longer ischemia time were associated with decreased postoperative glomerular filtration rate (p <0.05). When percentage of parenchyma spared was incorporated into the analysis, this factor and preoperative glomerular filtration rate proved to be the primary determinants of ultimate renal function, and duration of ischemia lost statistical significance.

    Conclusions:

    This nonrandomized, comparative study suggests that within the relatively strict parameters of conventional practice, ie predominantly short ischemic intervals and liberal use of hypothermia, ischemia time was not an independent predictor of ultimate renal function after partial nephrectomy. Long-term renal function after partial nephrectomy is determined primarily by the quantity and quality of renal parenchyma preserved, although type and duration of ischemia remain the most important modifiable factors, and warrant further study.

    References

    • 1 : Guideline for management of the clinical T1 renal mass. J Urol2009; 182: 1271. LinkGoogle Scholar
    • 2 : Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol2006; 7: 735. Google Scholar
    • 3 : Renal functional outcomes after partial nephrectomy with extended ischemic intervals are better than after radical nephrectomy. J Urol2010; 184: 1286. LinkGoogle Scholar
    • 4 : The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy. BJU Int2005; 95: 377. Google Scholar
    • 5 : Temporary renal ischemia during nephron sparing surgery is associated with short-term but not long-term impairment in renal function. J Urol2006; 176: 1339. LinkGoogle Scholar
    • 6 : The impact of ischemia time during open nephron sparing surgery on solitary kidneys: a multi-institutional study. J Urol2007; 177: 471. LinkGoogle Scholar
    • 7 : Factors predicting renal functional outcome after partial nephrectomy. J Urol2008; 180: 2363. LinkGoogle Scholar
    • 8 : Assessing the impact of ischaemia time during partial nephrectomy. Eur Urol2009; 56: 625. Google Scholar
    • 9 : Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol2010; 58: 340. Google Scholar
    • 10 : Impact of ischemia during laparoscopic partial nephrectomy: a multicenter study. J Urol2010; 183: 1714. LinkGoogle Scholar
    • 11 : Recovery of renal function after open and laparoscopic partial nephrectomy. Eur Urol2010; 58: 596. Google Scholar
    • 12 : Renal hypothermia: in vivo and ex vivo. Urol Clin North Am1983; 10: 637. Google Scholar
    • 13 : Surgical renal ischemia: a contemporary overview. J Urol2008; 180: 19. LinkGoogle Scholar
    • 14 : Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery1992; 111: 518. Google Scholar
    • 15 : A new equation to estimate glomerular filtration rate. Ann Intern Med2009; 150: 604. Google Scholar
    • 16 : Performance of the Chronic Kidney Disease-Epidemiology Study equations for estimating glomerular filtration rate before and after nephrectomy. J Urol2010; 183: 896. LinkGoogle Scholar
    • 17 : R: A language and environment for statistical computing: R Foundation for Statistical Computing, Vienna, Austria . 2009. www.R-project.org. Google Scholar
    • 18 : Renal function assessment in the era of chronic kidney disease: renewed emphasis on renal function centered patient care. J Urol2009; 182: 435. LinkGoogle Scholar
    • 19 : Pararenal aortic aneurysms: the future of open aortic aneurysm repair. J Vasc Surg1999; 29: 902. Google Scholar
    • 20 : Acute kidney injury: novel biomarkers and potential utility for patient care in urology. Urology2010; . Epub ahead of print. Google Scholar
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