The preoperative stratification of patients based on renal scan data is unable to predict the functional outcome after partial nephrectomy

ABSTRACT Introduction: eGFR-categories are used to predict functional outcome after partial nephrectomy (PN); no study categorized patients according to preoperative renal scan (RS) data. Aim of the study was to evaluate if stratification of patients according to RS is a reliable method to predict minor/major loss of renal function after PN. Materials and Methods: We considered patients who underwent PN and RS pre-/post-PN for T1 tumor in our Institution (2007-2017). Demographics, perioperative and specifically functional data were analysed. On the basis of the baseline Split Renal Function (SRF), patients were stratified into risk-categories: 1) baseline operated-kidney SRF range 45-55%; 2) baseline operated-kidney SRF <45%. Risk categories were analysed with postoperative functional outcome: postoperative operated-kidney SRF decrease below 90% of baseline was considered significant loss of function. Contingency tables and univariate/multivariate regression were analysed looking for independent factors of postoperative functional impairment. Results: 224 patients were analysed, 125 (55.8%) maintained >90% of their baseline function. Worse probability of maintaining ≥90 baseline renal function was found in patients with Charlson's Comorbidity Index (CCI≥3) (p=0.004) and patients with PADUA score ≥8 (p=0.023). After stratification by baseline renal function, ischemia was the only independent factor: no effect on patients with poorer baseline renal function. Patients with baseline SRF 45-55% who did not experience ischemia had the highest probability to maintain ≥90% baseline SRF (p=0.028). Ischemia >25 minutes was detrimental (p=0.017). Conclusions: Stratification of patients by SRF before PN is not a reliable predictor of renal functional outcome. Ischemia seems to scarcely influence patients with poorer renal function.

Glomerular loss after arteriovenous and arterial clamping for renal warm ischemia in a swine model

ABSTRACT PURPOSE: To evaluate the glomerular loss after arteriovenous or arterial warm ischemia in a swine model. METHODS: Twenty four pigs were divided into Group Sham (submitted to all surgical steps except the renal ischemia), Group AV (submitted to 30 minutes of warm ischemia by arteriovenous clamping of left kidney vessels), and Group A (submitted to 30 minutes of ischemia by arterial clamping). Right kidneys were used as controls. Weigh, volume, cortical volume, glomerular volumetric density (Vv[Glom]), volume-weighted glomerular volume (VWGV), and the total number of glomeruli were measured for each organ. RESULTS: Group AV showed a 24.5% reduction in its left kidney Vv[Glom] and a 25.4% reduction in the VWGV, when compared to the right kidney. Reductions were also observed when compared to kidneys of sham group. There was a reduction of 19.2% in the total number of glomeruli in AV kidneys. No difference was observed in any parameters analyzed on the left kidneys from group A. CONCLUSIONS: Renal warm ischemia of 30 minutes by arterial clamping did not caused significant glomerular damage, but arteriovenous clamping caused significant glomerular loss in a swine model. Clamping only the renal artery should be considered to minimize renal injury after partial nephrectomies.

Predictive factors of prolonged warm ischemic time (> or =30 minutes) during partial nephrectomy under pneumoperitoneum

PURPOSE: Current clinical data support a safe warm ischemia time (WIT) limit of 30 minutes during laparoscopic partial nephrectomy (LPN) or robot-assisted partial nephrectomy (RPN). We evaluated independent factors predicting prolonged WIT (more than 30 minutes) after LPN or RPN. MATERIALS AND METHODS: A retrospective data review was performed for 317 consecutive patients who underwent LPN or RPN performed by the same surgeon from October 2007 to May 2013. Patients were divided into two groups: group A was defined as prolonged WIT (> or =30 minutes) and group B as short WIT ( or =25 mm; odds ratio, 2.98; 95% confidence interval, 1.48-5.96; p=0.002), and surgeon experience (p<0.001) were independent predictors of prolonged WIT. CONCLUSIONS: Surgeon experience, tumor size, and PADUA score predicted prolonged WIT after RPN or LPN. Among these factors, increasing surgical experience with LPN or RPN is the most important factor for preventing prolonged WIT.

Protective response in renal transplantation: no clinical or molecular differences between open and laparoscopic donor nephrectomy

OBJECTIVE: Prolonged warm ischemia time and increased intra-abdominal pressure caused by pneumoperitoneum during a laparoscopic donor nephrectomy could enhance renal ischemia reperfusion injury. For this reason, laparoscopic donor nephrectomy may be associated with a slower graft function recovery. However, an adequate protective response may balance the ischemia reperfusion damage. This study investigated whether laparoscopic donor nephrectomy modified the protective response of renal tissue during kidney transplantation. METHODS: Patients undergoing live renal transplantation were prospectively analyzed and divided into two groups based on the donor nephrectomy approach used: 1) the control group, recipients of open donor nephrectomy (n = 29), and 2) the study group, recipients of laparoscopic donor nephrectomy (n = 26). Graft biopsies were obtained at two time points: T-1 = after warm ischemia time and T+1 = 45 minutes after kidney reperfusion. The samples were analyzed by immunohistochemistry for the Bcl-2 and HO-1 proteins and by real-time polymerase chain reaction for the mRNA expression of Bcl-2, HO-1 and vascular endothelial growth factor. RESULTS: The area under the curve for creatinine and delayed graft function were similar in both the laparoscopic and open groups. There was no difference in the protective gene expression between the laparoscopic donor nephrectomy and open donor nephrectomy groups. The protein expression of HO-1 and Bcl-2 were similar between the open and laparoscopic groups. Furthermore, the gene expression of B-cell lymphoma 2 correlated with the warm ischemia time in the open group (p = 0.047) and that of vascular endothelial growth factor with the area under the curve for creatinine in the laparoscopic group (p = 0.01). CONCLUSION: The postoperative renal function and protective factor expression were similar between laparoscopic ...

Detection of bronchial function of NHBD lung following one-h warm ischemia by organ bath model / 华中科技大学学报（医学）（英德文版）

This study investigated the feasibility and effects of organ bath to be used for detection of bronchial function of non-heart-beating donor (NHBD) lung after 1-h warm ischemia. Sixteen Swedish pigs were divided into two groups randomly: heart-beating donor (HBD) group and NHBD with 1-h warm ischemia (NHBD-1 h) group. The bronchial rings whose lengths and inner diameters were both 1.5 mm were obtained from isolated left lungs of all the pigs. Acetylcholine, arachidonic acid natrium and papaverine were used to test and compare the contractile and relaxant function of bronchial smooth muscles and epithelium-dependent relaxation (EpiDR) response between HBD and NHBD-1 h groups. The results showed that there was no significant difference in the values of bronchial precontraction between HBD and NHBD-1 h groups (5.18+/-0.07 vs 5.10+/-0.11 mN, P>0.05). No significant difference in the values of EpiDR responses between HBD and NHBD-1 h groups (1.26+/-0.05 vs 1.23+/-0.07 mN, P>0.05) was observed either. During the process of EpiDR induction, the rings had no spontaneous relaxation in two groups. In addition, papaverine solution completely relaxed the bronchial smooth muscles of all bronchial rings. It was concluded that after warm ischemia for 1 h, the contractile and relaxant abilities of bronchial smooth muscles, and the epithelium-dependent adjustment both kept intact. Organ bath model could be a liable and scientific way to evaluate the bronchial function of NHBD lung.

Efeito da estreptoquinase e alopurinol em um modelo de reimplante de membro após isquemia quente: Estudo experimental em ratos / Streptoquinase and allopurinol effect in a limb replantation model after warm ischemia: experimental study in mice

A isquemia prolongada leva a alterações na microcirculação tecidual e à liberação de radicais livres do oxigênio, conhecidos como fenômeno de não reperfusão. Foi testado o efeito da administração de alupurinol e de estreptoquinase, em um modelo experimental, de reimplante de membro após isquemia quente em ratos. Foi realizada a amputação, com preservação de vasos e nervos do membro posterior direito, em 110 ratos. Os grupos GM1, GM2, GM3, GM4 e GM5 foram submetidos a isquemia quente de 0, 2, 4, 6 e 8 horas. As taxas de viabilidade dos membros isquêmicos, após 7 dias de avaliação, foram 100, 80, 63,6, 50 e 20, respectivamente. Os grupos GE1, GE2 e GE3 foram tratados com estreptoquinase, alopurinol e com estreptoquinase e alopurinol combinados, após isquemia de 6 horas. As taxas de viabilidade foram 66,7, 70 e 70, respectivamente. Os resultados foram analisados estatisticamente, pelo teste do Qui-quadrado, e considerados significantes quando p< 0,05. Os grupos GM1, GM2, GM3, GM4 e GM5 foram diferentes entre si, exceto os grupos GM3 e GM4. GE1, GE2 e GE3 resultaram em uma viabilidade de mem bros maior que GM4, mas não em relação ao GM3. Os resultados sugerem um aumento da viabilidade de membros isquêmicos, após 6 horas e utilização do alopurinol e estreptoquinase. A utilização do alopurinol combinado com estreptoquinase não apre- sentou efeito sinérgico.

Prolonged ischemia leads to alterations in the microcirculation and oxygen free radicals production, event called no reflow phenomenon. It was tested the effectiveness of estreptoquinase and allopurinol in a new limb replantation model after warm ischemia. Amputation with preservation of vessels and nerves of the right hind limb was proceeded in 110 rats. The model groups MG1, MG2, MG3, MG4 and MG5 were submitted to 0, 2, 4, 6 and 8 hours of warm ischemia. The viability limb rates in each model group after 7 days of evaluation were 100, 80, 63, 6, 50, 20. The experimental groups EG1, EG2 and EG3 were treated with streptoquinase, allopurinol and both drugs after 6 hours of ischemia. Limb viability rates were 66.7, 70 and 70. Results were submitted to Q-square statistical analysis and p<0.05 was considered statistically significant. MG1, MG2, MG3, MG4 and MG5 were statistically different except for MG3 and MG4. EG1 had a better limb viability rate than MG4, but not than MG3. EG2 had a better result than MG4, but not than MG2 and MG3. EG3 had a better limb viability rate than MG4, but not than MG2 and MG3. The results suggest that the administration of allopurinol and streptoquinase after 6 hours of warm ischemia may be helpful to improve limb salvage. Administration of streptoquinase and allopurinol combined did not result a synergic effect.