缺血性和非缺血性腹腔镜与开放性肾部分切除术治疗肾细胞癌的肾功能结局。
Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer.
机构信息
University Hospital Basel, Urological University Clinic Basel-Liestal, Spitalstrasse 21, 4051, Basel, Switzerland.
Department of Urology, Karolinska - University Hospital, Solna, Stockholm, Sweden.
出版信息
BMC Nephrol. 2019 Feb 4;20(1):40. doi: 10.1186/s12882-019-1215-3.
BACKGROUND
Nephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Compared to radical nephrectomy, kidney failure and cardiovascular events are less frequent with NSS. However, the effects of different surgical approaches and of zero ischaemia on the postoperative reduction in renal function remain controversial. We aimed to investigate the relative short- and long-term changes in estimated glomerular filtration rate (eGFR) after ischaemic or zero-ischaemic open (ONSS) and laparoscopic NSS (LNSS) for RCC, and to analyse prognostic factors for postoperative acute kidney injury (AKI) and chronic kidney disease (CKD) stage ≥3.
METHODS
Data of 444 patients (211 LNSS, 233 ONSS), including 57 zero-ischaemic cases, were retrospectively analysed. Multiple regression models were used to predict relative changes in renal function. Natural cubic splines were used to demonstrate the association between ischaemia time (IT) and relative changes in renal function.
RESULTS
IT was identified as significant risk factor for short-term relative changes in eGFR (ß = - 0.27) and development of AKI (OR, 1.02), but no effect was found on long-term relative changes in eGFR. Natural cubic splines revealed that IT had a greater effect on patients with baseline eGFR categories ≥G3 concerning short-term decrease in renal function and development of AKI. Unlike LNSS, ONSS was significantly associated with short-term decrease in renal function (ß = - 13.48) and development of AKI (OR, 3.87). Tumour diameter was associated with long-term decrease in renal function (ß = - 1.76), whereas baseline eGFR was a prognostic factor for both short- (ß = - 0.20) and long-term (ß = - 0.29) relative changes in eGFR and the development of CKD stage ≥3 (OR, 0.89).
CONCLUSIONS
IT is a significant risk factor for AKI. The short-term effect of IT is not always linear, and the impact also depends on baseline eGFR. Unlike LNSS, ONSS is associated with the development of AKI. Our findings are helpful for surgical planning, and suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-time impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3.
背景
保肾手术（NSS）仍然是局部肾细胞癌（RCC）治疗的金标准，即使在对侧肾脏正常的情况下也是如此。与根治性肾切除术相比，NSS 发生肾功能衰竭和心血管事件的频率较低。然而，不同的手术方法和无缺血对术后肾功能下降的影响仍存在争议。我们旨在研究缺血或零缺血开放（ONSS）和腹腔镜肾部分切除术（LNSS）治疗 RCC 后估算肾小球滤过率（eGFR）的短期和长期变化，并分析术后急性肾损伤（AKI）和慢性肾脏病（CKD）≥3 期的预后因素。
方法
回顾性分析了 444 例患者（211 例 LNSS，233 例 ONSS）的数据，其中 57 例为零缺血病例。使用多元回归模型预测肾功能的相对变化。使用自然三次样条显示缺血时间（IT）与肾功能相对变化之间的关系。
结果
IT 是 eGFR 短期相对变化（ß=-0.27）和 AKI 发展的显著危险因素（OR，1.02），但对 eGFR 的长期相对变化没有影响。自然三次样条显示，在基线 eGFR 类别≥G3 的患者中，IT 对短期肾功能下降和 AKI 的发生有更大的影响。与 LNSS 不同，ONSS 与短期肾功能下降（ß=-13.48）和 AKI 发展（OR，3.87）显著相关。肿瘤直径与长期肾功能下降（ß=-1.76）相关，而基线 eGFR 是短期（ß=-0.20）和长期（ß=-0.29）eGFR 相对变化及 CKD 进展≥3 期（OR，0.89）的预后因素。
结论
IT 是 AKI 的一个重要危险因素。IT 的短期影响并非总是线性的，其影响还取决于基线 eGFR。与 LNSS 不同，ONSS 与 AKI 的发生有关。我们的研究结果有助于手术计划，建议应用无夹闭肾部分切除术技术或至少尽可能缩短缺血时间，以降低肾功能短期受损的风险，从而预防 AKI，特别是在基线 eGFR 类别≥G3 的患者中。
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