Lane Brian R, Babineau Denise C, Poggio Emilio D, Weight Christopher J, Larson Benjamin T, Gill Inderbir S, Novick Andrew C
Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
J Urol. 2008 Dec;180(6):2363-8; discussion 2368-9. doi: 10.1016/j.juro.2008.08.036. Epub 2008 Oct 18.
Compared to radical nephrectomy, partial nephrectomy better preserves renal parenchyma and function. Although several clinical factors may impact renal function after partial nephrectomy including preoperative function, age, gender and comorbidities, the contributions of tumor and surgical factors have not been well studied. We evaluate independent factors predicting functional outcomes after partial nephrectomy.
Preoperative and all postoperative serum creatinine values for 1,169 patients undergoing partial nephrectomy were used to estimate glomerular filtration rate. Postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate were analyzed using multiple pertinent covariates.
Median preoperative, postoperative nadir and ultimate glomerular filtration rates were 77, 57 and 71 ml per minute per 1.73 m(2), respectively. Increasing age, gender, lower preoperative glomerular filtration rate, solitary kidney, tumor size, ischemia time and longer time to nadir glomerular filtration rate significantly predicted postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate. Acute loss of renal function predicted lower ultimate glomerular filtration rate. In the entire cohort, in patients with normal preoperative renal function, and in those with baseline stage 3 and those with stage 4 chronic kidney disease the incidence of postoperative acute kidney injury after partial nephrectomy was 3.6%, 0.8%, 6.2% and 34%, and the incidence of chronic end stage renal disease after partial nephrectomy was 2.5%, 0.1%, 3.7% and 36%, respectively.
Lower preoperative glomerular filtration rate, solitary kidney, older age, gender, tumor size and longer ischemic interval all predicted lower glomerular filtration rate after partial nephrectomy. Therefore, duration of renal ischemia is the strongest modifiable surgical risk factor for decreased renal function after partial nephrectomy, and efforts to limit ischemic time and injury should be pursued in open and laparoscopic partial nephrectomy.
与根治性肾切除术相比，部分肾切除术能更好地保留肾实质和功能。尽管包括术前肾功能、年龄、性别和合并症在内的多种临床因素可能会影响部分肾切除术后的肾功能，但肿瘤和手术因素的作用尚未得到充分研究。我们评估预测部分肾切除术后功能结局的独立因素。
对1169例行部分肾切除术患者的术前及术后所有血清肌酐值进行检测，以估算肾小球滤过率。使用多个相关协变量分析术后最低肾小球滤过率和最终肾小球滤过率。
术前、术后最低及最终肾小球滤过率的中位数分别为每分钟每1.73平方米77、57和71毫升。年龄增加、性别、术前肾小球滤过率较低、孤立肾、肿瘤大小、缺血时间以及最低肾小球滤过率出现时间较长均显著预测术后最低肾小球滤过率和最终肾小球滤过率。肾功能急性丧失预示最终肾小球滤过率较低。在整个队列中，术前肾功能正常的患者、基线为3期慢性肾脏病的患者以及4期慢性肾脏病的患者，部分肾切除术后急性肾损伤的发生率分别为3.6%、0.8%、6.2%和34%，部分肾切除术后慢性终末期肾病的发生率分别为2.5%、0.1%、3.7%和36%。
术前肾小球滤过率较低、孤立肾、年龄较大、性别、肿瘤大小和较长的缺血间隔均预示部分肾切除术后肾小球滤过率较低。因此，肾缺血持续时间是部分肾切除术后肾功能下降最强的可改变手术危险因素，在开放性和腹腔镜部分肾切除术中应努力限制缺血时间和损伤。
