title: Functional recovery after partial nephrectomy: effects of volume loss and ischemic injury.
abstract: OBJECTIVE
  We used what is to our knowledge a new method to estimate volume loss after partial nephrectomy to assess the relative contributions of ischemic injury and volume loss on functional outcomes.
  
  
  METHODS
  We analyzed the records of 301 consecutive patients who underwent conventional partial nephrectomy between 2007 and 2010 with available data to meet inclusion criteria. Percent functional volume preservation was measured at a median of 1.4 years after surgery. Modification of diet in renal disease-2 estimated glomerular filtration rate was measured preoperatively and perioperatively, and a median of 1.2 years postoperatively. Statistical analysis was done to study associations.
  
  
  RESULTS
  Hypothermia or warm ischemia 25 minutes or less was applied in 75% of cases. Median percent functional volume preservation was 91% (range 38%-107%). Percent glomerular filtration rate preservation at nadir and late time points was 77% and 90% of preoperative glomerular filtration rate, respectively. On multivariate analysis percent functional volume preservation and warm ischemia time were associated with nadir glomerular filtration rate while only percent functional volume preservation was associated with late glomerular filtration rate (each p <0.001). Late percent glomerular filtration rate preservation and percent functional volume preservation were directly associated (p <0.001). Recovery of function to 90% or greater of percent functional volume preservation predicted levels was observed in 86% of patients. In patients with de novo postoperative stage 3 or greater chronic kidney disease, percent functional volume preservation and Charlson score were associated with late percent glomerular filtration rate preservation. Warm ischemia time was not associated with late functional glomerular filtration rate decreases in patients considered high risk for ischemic injury.
  
  
  CONCLUSIONS
  In this cohort volume loss and not ischemia time was the primary determinant of ultimate renal function after partial nephrectomy. Technical modifications aimed at minimizing volume loss during partial nephrectomy while still achieving negative margins may result in improved functional outcomes.
authors.affiliation: Sections of Urologic Oncology and Minimally Invasive and Robotic Urologic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA. simmonm2@ccf.org
authors.forename: Matthew N
authors.initials: MN
authors.lastname: Simmons
authors.forename: Shahab P
authors.initials: SP
authors.lastname: Hillyer
authors.forename: Byron H
authors.initials: BH
authors.lastname: Lee
authors.forename: Amr F
authors.initials: AF
authors.lastname: Fergany
authors.forename: Jihad
authors.initials: J
authors.lastname: Kaouk
authors.forename: Steven C
authors.initials: SC
authors.lastname: Campbell
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D050377:Cold Ischemia; D003404:Creatinine / Q000097:blood; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007511:Ischemia / Q000503:physiopathology*; D007668:Kidney / Q000098:blood supply* / Q000473:pathology / Q000503:physiopathology*; D007680:Kidney Neoplasms / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009392:Nephrectomy / Q000379:methods; D009929:Organ Size; D011184:Postoperative Period; D020127:Recovery of Function / Q000502:physiology*; D052096:Warm Ischemia; D055815:Young Adult
chemical_list: D003404:Creatinine