Kazama Akira, Munoz-Lopez Carlos, Lewis Kieran, Attawettayanon Worapat, Rathi Nityam, Maina Eran, Campbell Rebecca A, Wood Andrew, Lone Zaeem, Bartholomew Angelica, Kaouk Jihad, Haber Georges-Pascal, Haywood Samuel, Almassi Nima, Weight Christopher, Li Jianbo, Campbell Steven C
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Department of Urology, Molecular Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
BJU Int. 2025 Apr;135(4):611-620. doi: 10.1111/bju.16605. Epub 2024 Nov 28.
To evaluate the impact of prolonged ischaemia during partial nephrectomy (PN), which remains understudied despite its potential clinical relevance.
Of 1371 patients managed with on-clamp PN (2011-2014), 759 (55%) had imaging and assessment of serum creatinine levels before and after PN within the appropriate timeframes necessary for inclusion. This timeframe was chosen to allow for a robust analysis of both warm and cold ischaemia. Recovery from ischaemia (Rec) was defined as ipsilateral glomerular filtration rate (GFR) preserved, normalized by percentage of parenchymal volume preserved (PPVP), and would be 100% if all nephrons recovered completely from ischaemia. Pearson correlation and multivariable linear regression models were used to assess associations between Rec and ischaemia type and duration.
Of 759 patients, 525 (69%) were managed with warm ischaemia. The median warm/cold ischaemia times were 22 and 30 min, respectively. Overall, the median percent ipsilateral GFR preserved, PPVP and Rec were 79%, 83% and 96%, respectively. Segmented regression analysis demonstrated substantially greater decline in Rec, beginning at approximately 30 min for warm ischaemia, which was not observed for hypothermia. Prolonged ischaemia (defined as >30 min) occurred in 197 patients (26%; 88 warm/109 cold). For limited ischaemia (≤30 min), hypothermia was often used for tumours with increased tumour size and complexity (P < 0.01), while for prolonged ischaemia, the warm/cold subgroups had similar patient and tumour characteristics. For limited ischaemia and prolonged hypothermia, median Rec remained >95%, independent of ischaemia time. Differences in Rec between the warm and cold cohorts became significant only after 30 min (P < 0.05). On multivariable analysis, prolonged warm ischaemia was associated with reduced Rec (P = 0.02), which fell 3.9% for every additional 10 min beyond 30 min.
Our data suggest that Rec begins to decline significantly after 30 min during PN, although hypothermia was protective. Avoidance of prolonged warm ischaemia should be prioritized in patients with solitary kidneys and/or significant pre-existing chronic kidney disease.
评估部分肾切除术（PN）期间长时间缺血的影响，尽管其具有潜在的临床相关性，但仍未得到充分研究。
在1371例行钳夹式PN治疗的患者（2011 - 2014年）中，759例（55%）在PN前后的适当时间范围内进行了影像学检查及血清肌酐水平评估，这些时间范围是纳入研究所需的。选择该时间范围是为了对热缺血和冷缺血进行有力分析。缺血恢复（Rec）定义为同侧肾小球滤过率（GFR）得以保留，并通过保留的实质体积百分比（PPVP）进行标准化，如果所有肾单位完全从缺血中恢复，Rec将为100%。采用Pearson相关性分析和多变量线性回归模型评估Rec与缺血类型和持续时间之间的关联。
759例患者中，525例（69%）接受了热缺血治疗。热/冷缺血时间的中位数分别为22分钟和30分钟。总体而言，同侧GFR保留的中位数百分比、PPVP和Rec分别为79%、83%和96%。分段回归分析表明，Rec在热缺血约30分钟时开始显著下降，而低温缺血时未观察到这种情况。197例患者（26%；88例热缺血/109例冷缺血）出现长时间缺血（定义为>30分钟）。对于有限缺血（≤30分钟），低温常应用于肿瘤体积增大且复杂的患者（P < 0.01），而对于长时间缺血，热缺血/冷缺血亚组的患者和肿瘤特征相似。对于有限缺血和长时间低温缺血，Rec中位数保持>95%，与缺血时间无关。热缺血组和冷缺血组之间的Rec差异仅在30分钟后变得显著（P < 0.05）。多变量分析显示，长时间热缺血与Rec降低相关（P = 0.02），超过30分钟后，每增加10分钟，Rec下降3.9%。
我们的数据表明，PN期间30分钟后Rec开始显著下降，尽管低温具有保护作用。对于孤立肾和/或已有严重慢性肾病的患者，应优先避免长时间热缺血。
