Functional Recovery From Extended Warm Ischemia Associated With Partial Nephrectomy.
OBJECTIVE
To evaluate the impact of extended warm ischemia on incidence of acute kidney injury (AKI) and ultimate functional recovery after partial nephrectomy (PN), incorporating rigorous control for loss of parenchymal mass, and embedded within comparison to cohorts of patients managed with hypothermia or limited warm ischemia.


METHODS
From 2007 to 2014, 277 patients managed with PN had appropriate studies to evaluate changes in function/mass specifically within the operated kidney. Recovery from ischemia was defined as %function saved/%parenchymal mass saved. AKI was based on global renal function and defined as a ≥1.5-fold increase in serum creatinine above the preoperative level.


RESULTS
Hypothermia was utilized in 112 patients (median = 27 minutes) and warm ischemia in 165 (median = 21 minutes). AKI strongly correlated with solitary kidney (P < .001) and duration (P < .001) but not type (P = .49) of ischemia. Median recovery from ischemia in the operated kidney was 100% (interquartile range [IQR] = 88%-109%) for cold ischemia, with 6 (5%) noted to have <80% recovery from ischemia. For the warm ischemia group, median recovery from ischemia was 91% (IQR = 82%-101%, P < .001 compared with hypothermia), and 34 (21%) had recovery from ischemia <80% (P < .001). For warm ischemia subgrouped by duration <25 minutes (n = 114), 25-35 minutes (n = 35), and >35 minutes (n = 16), median recovery from ischemia was 92% (IQR = 86%-100%), 90% (IQR = 78%-104%), and 91% (IQR = 80%-96%), respectively (P = .77).


CONCLUSIONS
Our results suggest that AKI after PN correlates with duration but not with type of ischemia. However, subsequent recovery, which ultimately defines the new baseline glomerular filtration rate, is most reliable with hypothermia. However, most patients undergoing PN with warm ischemia still recover relatively strongly from ischemia, even if extended to 35-45 minutes.
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH; Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China.
Zhiling
Z
Zhang
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH; Ruijin Hospital, Department of Urology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Juping
J
Zhao
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH.
Lily
L
Velet
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH.
Cesar E
CE
Ercole
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH; Imaging Institute, Cleveland Clinic, Cleveland, OH.
Erick M
EM
Remer
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH.
Carme M
CM
Mir
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
Jianbo
J
Li
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH.
Toshio
T
Takagi
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH.
Sevag
S
Demirjian
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, OH. Electronic address: Campbes3@ccf.org.
Steven C
SC
Campbell
D058186:Acute Kidney Injury / Q000209:etiology / Q000517:prevention & control; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate / Q000502:physiology*; D006801:Humans; D007668:Kidney / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods*; D009929:Organ Size; D011184:Postoperative Period; D011859:Radiography; D020127:Recovery of Function; D012189:Retrospective Studies; D052096:Warm Ischemia / Q000379:methods*