Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
J Urol. 2011 Feb;185(2):421-7. doi: 10.1016/j.juro.2010.09.131. Epub 2010 Dec 17.
Factors that determine renal function after partial nephrectomy are not well-defined, including the impact of cold vs warm ischemia, and the relative importance of modifiable and nonmodifiable factors. We studied these determinants in a large cohort of patients with a solitary functioning kidney undergoing partial nephrectomy.
From 1980 to 2009, 660 partial nephrectomies were performed at 4 centers for tumor in a solitary functioning kidney under cold (300) or warm (360) ischemia. Data were collected in institutional review board approved registries and followup averaged 4.5 years. Preoperative and postoperative glomerular filtration rates were estimated via the Chronic Kidney Disease-Epidemiology Study equation.
At 3 months after partial nephrectomy median glomerular filtration rate decreased by equivalent amounts with cold or warm ischemia (21% vs 22%, respectively, p = 0.7), although median cold ischemic times were much longer (45 vs 22 minutes respectively, p <0.001). On multivariable analyses increasing age, larger tumor size, lower preoperative glomerular filtration rate and longer ischemia time were associated with decreased postoperative glomerular filtration rate (p <0.05). When percentage of parenchyma spared was incorporated into the analysis, this factor and preoperative glomerular filtration rate proved to be the primary determinants of ultimate renal function, and duration of ischemia lost statistical significance.
This nonrandomized, comparative study suggests that within the relatively strict parameters of conventional practice, ie predominantly short ischemic intervals and liberal use of hypothermia, ischemia time was not an independent predictor of ultimate renal function after partial nephrectomy. Long-term renal function after partial nephrectomy is determined primarily by the quantity and quality of renal parenchyma preserved, although type and duration of ischemia remain the most important modifiable factors, and warrant further study.
部分肾切除术（partial nephrectomy）后肾功能的决定因素尚不清楚，包括冷缺血与热缺血的影响，以及可改变和不可改变因素的相对重要性。我们研究了这些决定因素在接受部分肾切除术的单个功能肾肿瘤患者的大样本中。
1980 年至 2009 年，在 4 个中心，300 例患者采用冷缺血（cold ischemia），360 例患者采用热缺血（warm ischemia）行部分肾切除术。数据收集于机构审查委员会批准的注册系统，随访平均 4.5 年。术前和术后肾小球滤过率（glomerular filtration rate）通过慢性肾脏病流行病学合作研究（Chronic Kidney Disease-Epidemiology Study）方程进行估计。
部分肾切除术后 3 个月，冷缺血或热缺血后肾小球滤过率（glomerular filtration rate）等量下降（分别为 21%和 22%，p=0.7），尽管冷缺血时间中位数明显较长（分别为 45 分钟和 22 分钟，p<0.001）。多变量分析显示，年龄较大、肿瘤较大、术前肾小球滤过率较低和缺血时间较长与术后肾小球滤过率降低相关（p<0.05）。当保留的肾实质百分比纳入分析时，该因素和术前肾小球滤过率被证明是最终肾功能的主要决定因素，而缺血时间失去统计学意义。
本非随机、对照研究表明，在常规实践的相对严格参数范围内，即主要是短缺血间隔和低温的广泛应用，缺血时间不是部分肾切除术后最终肾功能的独立预测因素。部分肾切除术后的长期肾功能主要取决于保留的肾实质的数量和质量，尽管缺血类型和时间仍然是最重要的可改变因素，需要进一步研究。
