Toward Individualized Approaches to Partial Nephrectomy: Assessing the Correlation Between Ischemia Time and Patient Health Status (RECORD2 Project).

Health Status Humans Ischemia Nephrectomy / adverse effects Prospective Studies Retrospective Studies
Acute kidney injury Multimodal approach Nephron-sparing surgery Partial nephrectomy Preoperative counseling Renal cell carcinoma Renal function Warm ischemia

Journal

European urology oncology
ISSN: 2588-9311
Titre abrégé: Eur Urol Oncol
Pays: Netherlands
ID NLM: 101724904

Informations de publication

Date de publication:
08 2021
Historique:
received: 08 01 2020
revised: 13 05 2020
accepted: 20 05 2020
pubmed: 11 7 2020
medline: 2 2 2022
entrez: 11 7 2020
Statut: ppublish

Résumé

Ischemia time during partial nephrectomy (PN) is among the greatest determinants of acute kidney injury (AKI). Whether this association is affected by the preoperative risk of AKI has never been investigated. To assess the effect of the interaction between the preoperative risk of AKI and ischemia time on the probability of AKI during PN. Data of 944 patients treated with on-clamp PN for cT1 renal tumors were extracted from the Registry of Conservative and Radical Surgery for Cortical Renal Tumor Disease (RECORD2) database, a prospective multicenter project. We estimated the preoperative risk of AKI (defined according to the risk/injury/failure/loss/end-stage [RIFLE] criteria) according to age, baseline renal function, clinical stage, preoperative aspects and dimensions used for an anatomical (PADUA) score, and surgical approach. Classification and regression tree (CART) analysis identified patients at "high" and "low" risk of AKI. Finally, we plotted the probability of AKI over ischemia time stratified by the preoperative risk of AKI. Overall, 235 (25%) patients experienced AKI after surgery. At multivariable analysis, older patients, those with more complex tumors, those with higher baseline function, and those treated with open surgery had an increased risk of AKI (all p ≤ 0.011). According to the first split at CART analysis, patients were categorized as those with "high" and "low" risk of AKI having a probability of >40% or <40%. For low-risk patients, the probability of AKI in case of <10 versus >20 min of ischemia was 13% versus 28% (absolute risk increase 15%). The risk of AKI for high-risk patients who had <10 versus >20 min of ischemia was 31% versus 77%. This corresponds to an absolute risk increase of 45%. Limitations include retrospective data analyses and lack of surgeons' prior experience. Ischemia time during PN has different implications for patients with different health status. Clamp time seems less clinically relevant for patients in good conditions who may endure prolonged ischemia with a mild increase in the risk of AKI, whereas frail patients seem to be more vulnerable to ischemic damage even for short clamp time. For individualized intra- and postoperative management, duration of ischemia needs to be questioned in the context of the individual health status. Functional sequelae related to ischemia time during partial nephrectomy depend on baseline health status. The correlation between the duration of ischemia and baseline health status should be taken into account toward individualized intra- and postoperative management.

Sections du résumé

BACKGROUND
Ischemia time during partial nephrectomy (PN) is among the greatest determinants of acute kidney injury (AKI). Whether this association is affected by the preoperative risk of AKI has never been investigated.
OBJECTIVE
To assess the effect of the interaction between the preoperative risk of AKI and ischemia time on the probability of AKI during PN.
DESIGN, SETTING, AND PARTICIPANTS
Data of 944 patients treated with on-clamp PN for cT1 renal tumors were extracted from the Registry of Conservative and Radical Surgery for Cortical Renal Tumor Disease (RECORD2) database, a prospective multicenter project.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
We estimated the preoperative risk of AKI (defined according to the risk/injury/failure/loss/end-stage [RIFLE] criteria) according to age, baseline renal function, clinical stage, preoperative aspects and dimensions used for an anatomical (PADUA) score, and surgical approach. Classification and regression tree (CART) analysis identified patients at "high" and "low" risk of AKI. Finally, we plotted the probability of AKI over ischemia time stratified by the preoperative risk of AKI.
RESULTS AND LIMITATIONS
Overall, 235 (25%) patients experienced AKI after surgery. At multivariable analysis, older patients, those with more complex tumors, those with higher baseline function, and those treated with open surgery had an increased risk of AKI (all p ≤ 0.011). According to the first split at CART analysis, patients were categorized as those with "high" and "low" risk of AKI having a probability of >40% or <40%. For low-risk patients, the probability of AKI in case of <10 versus >20 min of ischemia was 13% versus 28% (absolute risk increase 15%). The risk of AKI for high-risk patients who had <10 versus >20 min of ischemia was 31% versus 77%. This corresponds to an absolute risk increase of 45%. Limitations include retrospective data analyses and lack of surgeons' prior experience.
CONCLUSIONS
Ischemia time during PN has different implications for patients with different health status. Clamp time seems less clinically relevant for patients in good conditions who may endure prolonged ischemia with a mild increase in the risk of AKI, whereas frail patients seem to be more vulnerable to ischemic damage even for short clamp time. For individualized intra- and postoperative management, duration of ischemia needs to be questioned in the context of the individual health status.
PATIENT SUMMARY
Functional sequelae related to ischemia time during partial nephrectomy depend on baseline health status. The correlation between the duration of ischemia and baseline health status should be taken into account toward individualized intra- and postoperative management.

Identifiants

DOI: 10.1016/j.euo.2020.05.009 PMID: 32646849
pubmed: 32646849
pii: S2588-9311(20)30076-6
doi: 10.1016/j.euo.2020.05.009
pii:
doi:

Types de publication

Journal Article Multicenter Study Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

645-650

Commentaires et corrections

Type : CommentIn

Informations de copyright

Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Auteurs

Carlo Andrea Bravi (CA)

Division of Oncology/Unit of Urology, URI-Urological Research Institute, Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy.

Andrea Mari (A)

Department of Urology, University of Florence, Unit of oncologic minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy.

Alessandro Larcher (A)

Division of Oncology/Unit of Urology, URI-Urological Research Institute, Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy.

Daniele Amparore (D)

Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, School of Medicine, Orbassano, Turin, Italy.

Alessandro Antonelli (A)

Department of Urology, Ospedali Civili Hospital, University of Brescia, Brescia, Italy.

Walter Artibani (W)

Department of Urology, Azienda Ospedaliera Universitaria Integrata (A.O.U.I.), Verona, Italy.

Roberto Bertini (R)

Division of Oncology/Unit of Urology, URI-Urological Research Institute, Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy.

Pierluigi Bove (P)

Department of Urology, University Hospital of Tor Vergata, Rome, Italy.

Eugenio Brunocilla (E)

Department of Urology, University of Bologna, Bologna, Italy; Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy.

Luigi Da Pozzo (L)

Department of Urology, Papa Giovanni XXIII Hospital, Bergamo, Italy.

Fabrizio di Maida (F)

Department of Urology, University of Florence, Unit of oncologic minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy.

Cristian Fiori (C)

Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, School of Medicine, Orbassano, Turin, Italy.

Andrea Gallioli (A)

Department of Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.

Paolo Gontero (P)

Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Turin, Turin, Italy.

Vincenzo Li Marzi (V)

Department of Urology, Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy.

Nicola Longo (N)

Department of Urology, University Federico II, Naples, Italy.

Vincenzo Mirone (V)

Department of Urology, University Federico II, Naples, Italy.

Francesco Porpiglia (F)

Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, School of Medicine, Orbassano, Turin, Italy.

Bernardo Rocco (B)

Department of Urology, Ospedale Policlinico e Nuovo Ospedale Civile S. Agostino Estense Modena, University of Modena and Reggio Emilia, Modena, Italy.

Riccardo Schiavina (R)

Department of Urology, University of Bologna, Bologna, Italy; Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy.

Luigi Schips (L)

Department of Urology, SS Hospital. Annunziata, Chieti, Italy.

Claudio Simeone (C)

Department of Urology, Ospedali Civili Hospital, University of Brescia, Brescia, Italy.

Salvatore Siracusano (S)

Department of Urology, Azienda Ospedaliera Universitaria Integrata (A.O.U.I.), Verona, Italy.

Riccardo Tellini (R)

Department of Urology, University of Florence, Unit of oncologic minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy.

Carlo Terrone (C)

Department of Urology, University of Genova, Genova, Italy.

Carlo Trombetta (C)

U.C.O. Clinica Urologica, Università degli Studi di Trieste, Trieste, Italy.

Vincenzo Ficarra (V)

Department of Human and Paediatric Pathology, Gaetano Barresi, Urologic Section, University of Messina, Messina, Italy.

Marco Carini (M)

Department of Urology, University of Florence, Unit of oncologic minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy.

Francesco Montorsi (F)

Division of Oncology/Unit of Urology, URI-Urological Research Institute, Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy.

Umberto Capitanio (U)

Division of Oncology/Unit of Urology, URI-Urological Research Institute, Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy.

Andrea Minervini (A)

Department of Urology, University of Florence, Unit of oncologic minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy. Electronic address: andreamine@libero.it.

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Classifications MeSH

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