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Saitta C, Afari JA, Autorino R, Capitanio U, Porpiglia F, Amparore D, Piramide F, Cerrato C, Meagher MF, Noyes SL, Pandolfo SD, Buffi NM, Larcher A, Hakimi K, Nguyen MV, Puri D, Diana P, Fasulo V, Saita A, Lughezzani G, Casale P, Antonelli A, Montorsi F, Lane BR, Derweesh IH. Development of a novel score (RENSAFE) to determine probability of acute kidney injury and renal functional decline post surgery: A multicenter analysis. Urol Oncol 2023; 41:487.e15-487.e23. [PMID: 37880003 DOI: 10.1016/j.urolonc.2023.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/15/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To create and validate 2 models called RENSAFE (RENalSAFEty) to predict postoperative acute kidney injury (AKI) and development of chronic kidney disease (CKD) stage 3b in patients undergoing partial (PN) or radical nephrectomy (RN) for kidney cancer. METHODS Primary objective was to develop a predictive model for AKI (reduction >25% of preoperative eGFR) and de novo CKD≥3b (<45 ml/min/1.73m2), through stepwise logistic regression. Secondary outcomes include elucidation of the relationship between AKI and de novo CKD≥3a (<60 ml/min/1.73m2). Accuracy was tested with receiver operator characteristic area under the curve (AUC). RESULTS AKI occurred in 452/1,517 patients (29.8%) and CKD≥3b in 116/903 patients (12.8%). Logistic regression demonstrated male sex (OR = 1.3, P = 0.02), ASA score (OR = 1.3, P < 0.01), hypertension (OR = 1.6, P < 0.001), R.E.N.A.L. score (OR = 1.2, P < 0.001), preoperative eGFR<60 (OR = 1.8, P = 0.009), and RN (OR = 10.4, P < 0.0001) as predictors for AKI. Age (OR 1.0, P < 0.001), diabetes mellitus (OR 2.5, P < 0.001), preoperative eGFR <60 (OR 3.6, P < 0.001) and RN (OR 2.2, P < 0.01) were predictors for CKD≥3b. AUC for RENSAFE AKI was 0.80 and 0.76 for CKD≥3b. AKI was predictive for CKD≥3a (OR = 2.2, P < 0.001), but not CKD≥3b (P = 0.1). Using 21% threshold probability for AKI achieved sensitivity: 80.3%, specificity: 61.7% and negative predictive value (NPV): 88.1%. Using 8% cutoff for CKD≥3b achieved sensitivity: 75%, specificity: 65.7%, and NPV: 96%. CONCLUSION RENSAFE models utilizing perioperative variables that can predict AKI and CKD may help guide shared decision making. Impact of postsurgical AKI was limited to less severe CKD (eGFR<60 ml/min 71.73m2). Confirmatory studies are requisite.
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Affiliation(s)
- Cesare Saitta
- University of California: San Diego Health System, San Diego, CA; Department of Urology, IRCCS Humanitas Clinical and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Jonathan A Afari
- University of California: San Diego Health System, San Diego, CA
| | | | - Umberto Capitanio
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Porpiglia
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Daniele Amparore
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Federico Piramide
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Clara Cerrato
- University of California: San Diego Health System, San Diego, CA; Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Sabrina L Noyes
- Spectrum Health, Grand Rapids, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Nicolò M Buffi
- Department of Urology, IRCCS Humanitas Clinical and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | | | - Kevin Hakimi
- University of California: San Diego Health System, San Diego, CA
| | - Mimi V Nguyen
- University of California: San Diego Health System, San Diego, CA
| | - Dhruv Puri
- University of California: San Diego Health System, San Diego, CA
| | - Pietro Diana
- Department of Urology, IRCCS Humanitas Clinical and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Vittorio Fasulo
- Department of Urology, IRCCS Humanitas Clinical and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alberto Saita
- Department of Urology, IRCCS Humanitas Clinical and Research Hospital, Rozzano, Italy
| | - Giovanni Lughezzani
- Department of Urology, IRCCS Humanitas Clinical and Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Paolo Casale
- Department of Urology, IRCCS Humanitas Clinical and Research Hospital, Rozzano, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Brian R Lane
- Spectrum Health, Grand Rapids, Michigan State University College of Human Medicine, Grand Rapids, MI
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Zhang S, Jin D, Zhang Y, Wang T. Risk factors and predictive model for acute kidney Injury Transition to acute kidney disease in patients following partial nephrectomy. BMC Urol 2023; 23:156. [PMID: 37794388 PMCID: PMC10552238 DOI: 10.1186/s12894-023-01325-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 09/15/2023] [Indexed: 10/06/2023] Open
Abstract
PURPOSE Acute kidney disease (AKD) is believed to be involved in the transition from acute kidney injury (AKI) to chronic kidney disease in general populations, but little is understood about this possibility among kidney surgical populations. This study aimed to elucidate the incidence of AKD after partial nephrectomy and risk factors that promote the AKI to AKD transition. METHODS From January 2010 to January 2020, this study retrospectively collected a dataset of consecutive patients with renal masses undergoing partial nephrectomy in 4 urological centers. Cox proportional regression analyses were adopted to identify risk factors that promoted the AKI to AKD transition. To avoid overfitting, the results were then verified by logistic least absolute shrinkage and selection operator (LASSO) regression. A nomogram was then constructed and validated for AKI to AKD transition prediction. RESULTS AKI and AKD occurred in 228 (21.4%) and 42 (3.9%) patients among a total of 1062 patients, respectively. In patients with AKI, multivariable Cox regression analysis and LASSO regression identified that age (HR 1.078, 1.029-1.112, p < 0.001), baseline eGFR (HR 1.015, 1.001-1.030, p < 0.001), RENAL score (HR1.612, 1.067-2.437, p = 0.023), ischemia time > 30 min (HR 7.284, 2.210-23.999, p = 0.001), and intraoperative blood loss > 300ml (HR 8.641, 2.751-27.171, p < 0.001) were risk factors for AKD transition. These five risk factors were then integrated into a nomogram. The nomogram showed excellent discrimination, calibration, and clinical net benefit ability. CONCLUSION Around 3.9% patients following partial nephrectomy would transit from AKI to AKD. Intraoperative blood loss and ischemia time need to be diminished to avoid on-going functional decline. Our nomogram can accurately predict the transition from AKI to AKD.
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Affiliation(s)
- Sizhou Zhang
- Department of Urology, People's Hospital of Hechuan Chongqing, Chongqing, P.R. China
| | - Dachun Jin
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
- Department of Urology, Daping Hospital/Army Medical Center, Army Medical University, Chongqing, P.R. China
| | - Yuanfeng Zhang
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.
| | - Tianhui Wang
- Department of Urology, People's Hospital of Fengjie, Chongqing, P.R. China.
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Makevičius J, Čekauskas A, Želvys A, Ulys A, Jankevičius F, Miglinas M. Evaluation of Renal Function after Partial Nephrectomy and Detection of Clinically Significant Acute Kidney Injury. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050667. [PMID: 35630084 PMCID: PMC9144406 DOI: 10.3390/medicina58050667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Consequences of partial nephrectomy (PN), intraoperative hypotension (IOH) and postoperative neutrophil to lymphocyte ratio (NLR) may cause postoperative acute kidney injury (AKI) and in long-term-chronic kidney disease (CKD). Our study aimed to identify the AKI incidence after PN, to find clinically significant postoperative AKI and renal dysfunction, and to determine the predictor factors. Materials and Methods: A prospective observational study consisted of 91 patients who received PN with warm ischemia, and estimated preoperative glomerular filtration rate (eGFR) ≥ 60 mL/min and without abnormal albuminuria. Results: 38 (41.8%) patients experienced postoperative AKI. Twenty-one (24.1%) patients had CKD upstage after 1 year follow-up. Sixty-seven percent of CKD upstage patients had AKI 48 h after surgery and 11% after 2 months. All 15 (16.5%) patients with CKD had postoperative AKI. With IOH, OR 1.07, 95% CI 1.03−1.10 and p < 0.001, postoperative NLR after 48 h (OR 1.50, 95% CI 1.19−1.88, p < 0.001) was the major risk factor of AKI. In multivariate logistic regression analysis, the kidney’s resected part volume (OR 1.08, 95% CI 1.03−1.14, p < 0.001) and IOH (OR 1.10, 95% CI 1.04−1.15, p < 0.001) were retained as statistically significant prognostic factors for detecting postoperative renal dysfunction. The independent risk factor for clinically significant postoperative AKI was only IOH (OR, 1.06; p < 0.001). Only AKI with the CKD upstage group has a statistically significant effect (p < 0.0001) on eGFR 6 and 12 months after surgery. Conclusions: The presence of AKI after PN is not rare. IOH and NLR are associated with postoperative AKI. The most important predictive factor of postoperative AKI is an NLR of over 3.5. IOH is an independent risk factor for clinically significant postoperative AKI and together with kidney resected part volume effects postoperative renal dysfunction. Only clinically significant postoperative AKI influences the reduction of postoperative eGFR after 6 and 12 months.
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Affiliation(s)
- Jurijus Makevičius
- Institute of Clinical Medicine, Faculty of Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, M. K. Čiurlionio Str. 21/27, LT-03101 Vilnius, Lithuania; (A.Č.); (A.Ž.); (F.J.); (M.M.)
- Center of Urology, Vilnius University Hospital Santaros Klinikos, Santariškių Str. 2, LT-08660 Vilnius, Lithuania
- Correspondence:
| | - Albertas Čekauskas
- Institute of Clinical Medicine, Faculty of Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, M. K. Čiurlionio Str. 21/27, LT-03101 Vilnius, Lithuania; (A.Č.); (A.Ž.); (F.J.); (M.M.)
- Center of Urology, Vilnius University Hospital Santaros Klinikos, Santariškių Str. 2, LT-08660 Vilnius, Lithuania
| | - Arūnas Želvys
- Institute of Clinical Medicine, Faculty of Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, M. K. Čiurlionio Str. 21/27, LT-03101 Vilnius, Lithuania; (A.Č.); (A.Ž.); (F.J.); (M.M.)
- Center of Urology, Vilnius University Hospital Santaros Klinikos, Santariškių Str. 2, LT-08660 Vilnius, Lithuania
| | - Albertas Ulys
- Departament of Oncourology, National Cancer Institute, Santariškių Str. 1, LT-08661 Vilnius, Lithuania;
| | - Feliksas Jankevičius
- Institute of Clinical Medicine, Faculty of Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, M. K. Čiurlionio Str. 21/27, LT-03101 Vilnius, Lithuania; (A.Č.); (A.Ž.); (F.J.); (M.M.)
- Center of Urology, Vilnius University Hospital Santaros Klinikos, Santariškių Str. 2, LT-08660 Vilnius, Lithuania
| | - Marius Miglinas
- Institute of Clinical Medicine, Faculty of Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, M. K. Čiurlionio Str. 21/27, LT-03101 Vilnius, Lithuania; (A.Č.); (A.Ž.); (F.J.); (M.M.)
- Center of Nephrology, Vilnius University Hospital Santaros Klinikos, Santariškių Str. 2, LT-08661 Vilnius, Lithuania
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Wu Y, Chen J, Luo C, Chen L, Huang B. Predicting the risk of postoperative acute kidney injury: development and assessment of a novel predictive nomogram. J Int Med Res 2021; 49:3000605211032838. [PMID: 34382465 PMCID: PMC8366143 DOI: 10.1177/03000605211032838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to establish and internally verify the risk nomogram of postoperative acute kidney injury (AKI) in patients with renal cell carcinoma. METHODS We retrospectively collected data from 559 patients with renal cell carcinoma from June 2016 to May 2019 and established a prediction model. Twenty-six clinical variables were examined by least absolute shrinkage and selection operator regression analysis, and variables related to postoperative AKI were determined. The prediction model was established by multiple logistic regression analysis. Decision curve analysis was conducted to evaluate the nomogram. RESULTS Independent predictors of postoperative AKI were smoking, hypertension, surgical time, blood glucose, blood uric acid, alanine aminotransferase, estimated glomerular filtration rate, and radical nephrectomy. The C index of the nomogram was 0.825 (0.790-0.860) and 0.814 was still obtained in the internal validation. The nomogram had better clinical benefit when the intervention was decided at the threshold probabilities of >4% and <79% for patients and doctors, respectively. CONCLUSIONS This novel postoperative AKI nomogram incorporating smoking, hypertension, the surgical time, blood glucose, blood uric acid, alanine aminotransferase, the estimated glomerular filtration rate, and radical nephrectomy is convenient for facilitating the individual postoperative risk prediction of AKI in patients with renal cell carcinoma.
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Affiliation(s)
- Yukun Wu
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Junxing Chen
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Cheng Luo
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lingwu Chen
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bin Huang
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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Wu QF, Kong H, Xu ZZ, Li HJ, Mu DL, Wang DX. Impact of goal-directed hemodynamic management on the incidence of acute kidney injury in patients undergoing partial nephrectomy: a pilot randomized controlled trial. BMC Anesthesiol 2021; 21:67. [PMID: 33658007 PMCID: PMC7927248 DOI: 10.1186/s12871-021-01288-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 02/24/2021] [Indexed: 11/28/2022] Open
Abstract
Background The incidence of acute kidney injury (AKI) remains high after partial nephrectomy. Ischemia-reperfusion injury produced by renal hilum clamping during surgery might have contributed to the development of AKI. In this study we tested the hypothesis that goal-directed fluid and blood pressure management may reduce AKI in patients following partial nephrectomy. Methods This was a pilot randomized controlled trial. Adult patients who were scheduled to undergo partial nephrectomy were randomized into two groups. In the intervention group, goal-directed hemodynamic management was performed from renal hilum clamping until end of surgery; the target was to maintain stroke volume variation < 6%, cardiac index 3.0–4.0 L/min/m2 and mean arterial pressure > 95 mmHg with crystalloid fluids and infusion of dobutamine and/or norepinephrine. In the control group, hemodynamic management was performed according to routine practice. The primary outcome was the incidence of AKI within the first 3 postoperative days. Results From June 2016 to January 2017, 144 patients were enrolled and randomized (intervention group, n = 72; control group, n = 72). AKI developed in 12.5% of patients in the intervention group and in 20.8% of patients in the control group; the relative reduction of AKI was 39.9% in the intervention group but the difference was not statistically significant (relative risk 0.60, 95% confidence interval [CI] 0.28–1.28; P = 0.180). No significant differences were found regarding AKI classification, change of estimated glomerular filtration rate over time, incidence of postoperative 30-day complications, postoperative length of hospital stay, as well as 30-day and 6-month mortality between the two groups. Conclusion For patients undergoing partial nephrectomy, goal-directed circulatory management during surgery reduced postoperative AKI by about 40%, although not significantly so. The trial was underpowered. Large sample size randomized trials are needed to confirm our results. Trial registration Clinicaltrials.gov identifier: NCT02803372. Date of registration: June 6, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01288-8.
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Affiliation(s)
- Qiong-Fang Wu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Zhen-Zhen Xu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Huai-Jin Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Dong-Liang Mu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China. .,Outcomes Research Consortium, Cleveland, OH, USA.
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Thongprayoon C, Hansrivijit P, Kovvuru K, Kanduri SR, Torres-Ortiz A, Acharya P, Gonzalez-Suarez ML, Kaewput W, Bathini T, Cheungpasitporn W. Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm. J Clin Med 2020; 9:E1104. [PMID: 32294894 PMCID: PMC7230860 DOI: 10.3390/jcm9041104] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common clinical condition among patients admitted in the hospitals. The condition is associated with both increased short-term and long-term mortality. With the development of a standardized definition for AKI and the acknowledgment of the impact of AKI on patient outcomes, there has been increased recognition of AKI. Two advances from past decades, the usage of computer decision support and the discovery of AKI biomarkers, have the ability to advance the diagnostic method to and further management of AKI. The increasingly widespread use of electronic health records across hospitals has substantially increased the amount of data available to investigators and has shown promise in advancing AKI research. In addition, progress in the finding and validation of different forms of biomarkers of AKI within diversified clinical environments and has provided information and insight on testing, etiology and further prognosis of AKI, leading to future of precision and personalized approach to AKI management. In this this article, we discussed the changing paradigms in AKI: from mechanisms to diagnostics, risk factors, and management of AKI.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17105, USA;
| | - Karthik Kovvuru
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Swetha R. Kanduri
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Aldo Torres-Ortiz
- Department of Medicine, Ochsner Medical Center, New Orleans, LA 70121, USA;
| | - Prakrati Acharya
- Division of Nephrology, Department of Medicine, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA;
| | - Maria L. Gonzalez-Suarez
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85724, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
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