Munoz-Lopez Carlos, Lewis Kieran, Attawettayanon Worapat, Yasuda Yosuke, Emrich Accioly João Pedro, Rathi Nityam, Lone Zaeem, Boumitri Melissa, Campbell Rebecca A, Wood Andrew, Kaouk Jihad H, Haber Georges-Pascal, Eltemamy Mohamad, Krishnamurthi Venkatesh, Abouassaly Robert, Haywood Samuel C, Weight Christopher J, Campbell Steven C
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Division of Urology, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand.
BJU Int. 2023 Aug;132(2):202-209. doi: 10.1111/bju.16023. Epub 2023 Apr 19.
To provide a more rigorous assessment of factors affecting functional recovery after partial nephrectomy (PN) using novel tools that allow for analysis of more patients and improved accuracy for assessment of parenchymal volume loss, thereby revealing the potential impact of secondary factors such as ischaemia.
Of 1140 patients managed with PN (2012-2014), 670 (59%) had imaging and serum creatinine levels measured before and after PN necessary for inclusion. Recovery from ischaemia was defined as the ipsilateral glomerular filtration rate (GFR) saved normalised by parenchymal volume saved. Acute kidney injury was assessed through Spectrum Score, which quantifies the degree of acute ipsilateral renal dysfunction due to exposure to ischaemia that would otherwise be masked by the contralateral kidney. Multivariable regression was used to identify predictors of Spectrum Score and Recovery from Ischaemia.
In all, 409/189/72 patients had warm/cold/zero ischaemia, respectively, with median (interquartile range [IQR]) ischaemia times for cold and warm ischaemia of 30 (25-42) and 22 (18-28) min, respectively. The median (IQR) global preoperative GFR and new baseline GFR (NBGFR) were 78 (63-92) and 69 (54-81) mL/min/1.73 m , respectively. The median (IQR) ipsilateral preoperative GFR and NBGFR were 40 (33-47) and 31 (24-38) mL/min/1.73 m , respectively. Functional recovery correlated strongly with parenchymal volume preserved (r = 0.83, P < 0.01). The median (IQR) decline in ipsilateral GFR associated with PN was 7.8 (4.5-12) mL/min/1.73 m with loss of parenchyma accounting for 81% of this loss. The median (IQR) recovery from ischaemia was similar across the cold/warm/zero ischaemia groups at 96% (90%-102%), 95% (89%-101%), and 97% (91%-102%), respectively. Independent predictors of Spectrum Score were ischaemia time, tumour complexity, and preoperative global GFR. Independent predictors of recovery from ischaemia were insulin-dependent diabetes mellitus, refractory hypertension, warm ischaemia, and Spectrum Score.
The main determinant of functional recovery after PN is parenchymal volume preservation. A more robust and rigorous evaluation allowed us to identify secondary factors including comorbidities, increased tumour complexity, and ischaemia-related factors that are also independently associated with impaired recovery, although altogether these were much less impactful.
使用新型工具对影响部分肾切除术（PN）后功能恢复的因素进行更严格的评估，该工具可分析更多患者，并提高实质体积损失评估的准确性，从而揭示诸如缺血等次要因素的潜在影响。
在1140例接受PN治疗的患者（2012 - 2014年）中，670例（59%）具备纳入研究所需的PN前后的影像学检查及血清肌酐水平测量数据。缺血恢复定义为同侧肾小球滤过率（GFR）挽救值除以实质体积挽救值后进行标准化。通过Spectrum评分评估急性肾损伤，该评分量化了因缺血导致的同侧急性肾功能障碍程度，否则会被对侧肾脏掩盖。采用多变量回归分析来确定Spectrum评分和缺血恢复的预测因素。
总共409/189/72例患者分别经历了热缺血/冷缺血/零缺血，冷缺血和热缺血的中位（四分位间距[IQR]）缺血时间分别为30（25 - 42）分钟和22（18 - 28）分钟。术前总体GFR和新基线GFR（NBGFR）的中位（IQR）值分别为78（63 - 92）和69（54 - 81）mL/min/1.73m²。术前同侧GFR和NBGFR的中位（IQR）值分别为40（33 - 47）和31（24 - 38）mL/min/1.73m²。功能恢复与保留的实质体积密切相关（r = 0.83，P < 0.01）。与PN相关的同侧GFR的中位（IQR）下降值为7.8（4.5 - 12）mL/min/1.73m²，其中实质损失占该损失的81%。冷缺血/热缺血/零缺血组的缺血恢复中位（IQR）值相似，分别为96%（90% - 102%）、95%（89% - 101%）和97%（91% - 102%）。Spectrum评分的独立预测因素为缺血时间、肿瘤复杂性和术前总体GFR。缺血恢复的独立预测因素为胰岛素依赖型糖尿病、难治性高血压、热缺血和Spectrum评分。
PN后功能恢复的主要决定因素是实质体积的保留。更强大和严格的评估使我们能够识别包括合并症、肿瘤复杂性增加和缺血相关因素在内的次要因素，这些因素也与恢复受损独立相关，尽管总体而言其影响要小得多。
