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      Risk factors for acute renal failure in nephrectomized patients treated in a university hospital

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          Abstract

          Background

          New surgical techniques for nephrectomy mainly related to early diagnosis made possible by advances in imaging studies have been developed in recent decades. However, postoperative renal dysfunction is a constant concern because of the major problems faced by healthcare services and by the patients themselves. To assess risk factors for developing acute renal failure (ARF) in patients submitted to nephrectomy in a university hospital.

          Methods

          Seventy-seven patients submitted to nephrectomy for benign and malignant diseases in a university hospital were evaluated in respect to preoperative and postoperative creatinine clearance. Demographic (gender, age), clinical (cancer, diabetes, high blood pressure, chronic kidney disease) and surgical (anesthesia time, open or laparoscopic surgery) variables were also analyzed.

          Results

          Of the 77 patients, 72 met the inclusion criteria. Of these, ten (13.8%) had a diagnosis of chronic renal failure (CRF), 30 (48%) had stage I ARF and one (16.1%) had stage II ARF. The anesthesia time, type of surgery (open or laparoscopy), total or partial nephrectomy, the side of the procedure, hypertension, diabetes, CRF, renal cancer, preoperative and postoperative creatinine concentrations were analyzed. Only the difference between preoperative and postoperative creatinine clearance was clinically significant (P<0.001).

          Conclusions

          An altered preoperative renal function is a risk factor for the development of ARF in nephrectomized patients.

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          Most cited references 13

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          Surgical management of renal tumors 4 cm. or less in a contemporary cohort.

           J. Lee,  J J KATZ,  W Shi (2000)
          We evaluated a patient cohort with renal tumors 4 cm. or less treated with partial or radical nephrectomy. We compared patient and tumor characteristics, and survival in these 2 groups. We retrospectively analyzed the records of 670 patients with a median age of 63 years treated surgically for renal cell carcinoma between July 31, 1989 and July 31, 1997. Renal tumors 4.0 cm. or less were noted in 252 patients (38%) who underwent a total of 262 procedures, including 183 radical (70%) and 79 partial (30%) nephrectomies. Ten patients required 2 operations each because of bilateral renal cell carcinoma. Median followup was 40 months. We compared clinicopathological parameters in the partial and radical nephrectomy groups using chi-square or Wilcoxon analysis as appropriate. Survival analysis was determined by the log rank test and Cox regression model. The partial and radical nephrectomy groups were comparable with respect to gender ratio, tumor presentation, histological classification, pathological stage and complication rate. Median tumor size was 2.5 and 3.0 cm. in the partial and radical nephrectomy groups, respectively (p = 0.0001). Resection was incomplete in 1 patient (1.3%) in the partial and none in the radical nephrectomy group. There was no local recurrence after either procedure, and no significant difference in disease specific, disease-free and overall survival (p = 0.98, 0.23 and 0.20, respectively). Patients with a small renal tumor have similar perioperative morbidity, pathological stage and outcome regardless of treatment with partial or radical nephrectomy. Therefore, partial nephrectomy remains a safe alternative for tumors of this size.
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            Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses.

            Radical nephrectomy has traditionally been preferred to partial nephrectomy in patients with localized renal cell cancer because of its simplicity and established cancer control. Recent data suggest that these patients have significant competing risks of death, some of which may be increased by chronic renal insufficiency. Therefore, we compared overall survival, cancer specific survival and cardiac specific survival in patients undergoing partial or radical nephrectomy for cT1b tumors. From 1999 to 2006, 1,004 patients with renal masses between 4 and 7 cm underwent extirpative surgery, partial nephrectomy (524) or radical nephrectomy (480). We generated a propensity model based on preoperative patient characteristics, and then modeled survival with the additional variables of pathological stage and new baseline renal function. On multivariate analysis cancer specific survival was equivalent for patients treated with partial nephrectomy or radical nephrectomy. Those patients undergoing radical nephrectomy lost significantly more renal function than those undergoing partial nephrectomy. The average excess loss of renal function observed with radical nephrectomy was associated with a 25% (95% CI 3-73) increased risk of cardiac death and 17% (95% CI 12-27) increased risk of death from any cause on multivariate analysis. Partial nephrectomy offers cancer specific survival equivalent to that of radical nephrectomy and is technically feasible in at least 50% of patients with cT1b tumors. Preservation of renal function was significantly better in patients treated with partial nephrectomy. Postoperative renal insufficiency was a significant independent predictor of overall and cardiovascular specific survival, and efforts should be made to limit the renal function loss associated with surgery for localized renal masses. Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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              Renal function after partial nephrectomy: effect of warm ischemia relative to quantity and quality of preserved kidney.

              To evaluate the effects of warm ischemia time (WIT) and quantity and quality of kidney preserved on renal functional recovery after partial nephrectomy (PN). The effect of WIT relative to these other parameters has recently been challenged. We identified 362 consecutive patients with a solitary kidney who had undergone PN using warm ischemia. Multivariate models with multiple imputations were used to evaluate the associations with acute renal failure and new-onset stage IV chronic kidney disease (CKD). The median WIT was 21 minutes (range 4-55), the median percentage of kidney preserved was 80% (range 25%-98%), and the median preoperative glomerular filtration rate (GFR) was 61 mL/min/1.73 m2 (range 11-133). Postoperative acute renal failure occurred in 70 patients (19%). Of the 226 patients with a preoperative GFR>30 mL/min/1.73 m2, 38 (17%) developed new-onset stage IV CKD during follow-up. On multivariate analysis, the WIT (P=.021), percentage of kidney preserved (P=.009), and preoperative GFR (P 25 minutes remained significantly associated with new-onset stage IV CKD in a multivariate analysis adjusting for the quantity and quality factors (hazard ratio 2.27, P=.049). Our results have validated that the quality and quantity of kidney are the most important determinants of renal function after PN. In addition, we have also demonstrated that the WIT remains an important modifiable feature associated with short- and long-term renal function. The precision of surgery, maximizing the amount of preserved, vascularized parenchyma, should be a focus of study for optimizing the PN procedure. Copyright © 2012 Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Transl Androl Urol
                Transl Androl Urol
                TAU
                Translational Andrology and Urology
                AME Publishing Company
                2223-4691
                April 2017
                April 2017
                : 6
                : 2
                : 277-281
                Affiliations
                [1 ]Resident in Urology, Hospital de Base of the Medicine School in Sao Jose do Rio Preto (FAMERP), São Paulo, Brazil
                [2 ]Department of Urology, Hospital de Base of the Medicine School in Sao Jose do Rio Preto (FAMERP), São Paulo, Brazil
                [3 ]Department of Biostatistics, Hospital de Base of the Medicine School in Sao Jose do Rio Preto (FAMERP), São Paulo, Brazil
                Author notes

                Contributions: Conception and design: FN Fácio Júnior, JP Fantin, LC Spessoto; (II) Administrative support: FN Fácio Júnior, JP Fantin, LC Spessoto, L Castiglioni; (III) Provision of study materials or patients: FN Fácio Júnior, JP Fantin, R de Carvalho Neiva, M Gatti, PF de Arruda, T Antoniassi, LC Spessoto; (IV) Collection and assembly of data: FN Fácio Júnior, JP Fantin, R de Carvalho Neiva, M Gatti, PF de Arruda, T Antoniassi, LC Spessoto, JC Mesquita; (V) Data analysis and interpretation: FN Fácio Júnior, JP Fantin, R de Carvalho Neiva, L Castiglioni; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

                Correspondence to: Fernando Nestor Fácio Jr, MD, PhD. Department of Urology, Medical School of São José do Rio Preto, Ave. Fernando C. Pires 3600, CEP 15015-040, São Paulo, Brazil. Email: fnfacio@ 123456yahoo.com.br .
                Article
                tau-06-02-277
                10.21037/tau.2017.03.39
                5422694
                2017 Translational Andrology and Urology. All rights reserved.
                Categories
                Original Article

                renal insufficiency, nephrectomy, risk factors

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