Comparison of warm ischemia versus no ischemia during partial nephrectomy on a solitary kidney.

Abstract

BACKGROUND:

The safe duration of warm ischemia during partial nephrectomy (PN) remains controversial.

OBJECTIVE:

To compare the short- and long-term renal effects of warm ischemia versus no ischemia in patients with a solitary kidney.

DESIGN, SETTING, AND PARTICIPANTS:

Using the Cleveland Clinic and Mayo Clinic databases, we identified 458 patients who underwent open (n=411) or laparoscopic (n=47) PN for a renal mass in a solitary kidney between 1990 and 2008. Patients treated with cold ischemia were excluded.

MEASUREMENTS:

Associations of ischemia type (none vs warm) with short- and long-term renal function were evaluated using logistic or Cox regression models.

RESULTS AND LIMITATIONS:

No ischemia was used in 96 patients (21%), while 362 patients (79%) had a median of 21 min (range: 4-55) of warm ischemia. Patients treated with warm ischemia had a significantly higher preoperative glomerular filtration rate (GFR; median: 6 ml/min per 1.73 m(2) vs 54 ml/min per 1.73 m(2); p<0.001) and larger tumors (median: 3.4 cm vs 2.5 cm; p<0.001) compared with patients treated with no ischemia. Warm ischemia patients were significantly more likely to develop acute renal failure (odds ratio [OR]: 2.1; p=0.044) and a GFR <15 ml/min per 1.73 m(2) in the postoperative period (OR: 4.2; p=0.007) compared with patients who did not have hilar clamping. Among the 297 patients with a preoperative GFR >or=30 ml/min per 1.73 m(2), patients with warm ischemia were significantly more likely to develop new-onset stage IV chronic kidney disease (hazard ratio: 2.3; p=0.028) during a mean follow-up of 3.3 yr. Similar results were obtained adjusting for preoperative GFR, tumor size, and type of PN in a multivariable analysis. Limitations include surgeon selection bias when determining type of ischemia.

CONCLUSIONS:

Warm ischemia during PN is associated with adverse renal consequences. Although selection bias is present, PN without ischemia should be used when technically feasible in patients with a solitary kidney.

• Authors: R Houston Thompson, Brian R Lane, Christine M Lohse, Bradley C Leibovich, Amr Fergany, Igor Frank, Inderbir S Gill, Steven C Campbell, Michael L Blute
• Journal: European urology (Eur Urol) Vol. 58 Issue 3 Pg. 331-6 (Sep 2010) ISSN: 1873-7560 [Electronic] Switzerland
• PMID: 20557996 (Publication Type: Comparative Study, Journal Article)
• Copyright: (c) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Topics

• Adult
• Aged
• Aged, 80 and over
• Female
• Humans
• Kidney Diseases (complications)
• Kidney Neoplasms (complications, surgery)
• Male
• Middle Aged
• Nephrectomy (methods)
• Retrospective Studies
• Warm Ischemia (adverse effects)
• Young Adult