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Urologiia (Moscow, Russia : 1999) Mar 2022Clamping of the renal artery during partial nephrectomy leads to renal ischemia and a deterioration of its function. An alternative to total ischemia is to isolate and...
INTRODUCTION
Clamping of the renal artery during partial nephrectomy leads to renal ischemia and a deterioration of its function. An alternative to total ischemia is to isolate and clamp the segmental branch of the renal artery supplying the tumor.
AIM
To evaluate the efficiency of robot-assisted partial nephrectomy (RAPN) with selective renal ischemia.
MATERIAL AND METHODS
A total of 42 patients with renal tumors of stage T1a (n=34) and T1b (n=8) undergoing RAPN were included in the study. There were 25 men (59.5%) and 17 women. The mean age was 56.0 +/- 7.5 years, the tumor size ranged from 2.5 to 6.8 cm. Patients with a solitary kidney, multiple tumors, and those who underwent partial nephrectomy with clamping of the renal artery were excluded from the study. CT angiography with 3D reconstruction were used to detect the segmental branches of the renal artery, that supply the tumor. To determine the complexity of renal tumors, the RENAL nephrometric scale was used. Complications were assessed according to the Clavien-Dindo classification. In addition, mean operative time and volume of blood loss, warm ischemia time, pre- and postoperative renal function, and oncological outcomes were analyzed. The RAPN was considered successful if it was performed with selective clamping of the artery.
RESULTS
RAPN with selective ischemia was effective in 38 (90.5%) of 42 patients. In 4 (9.5%) cases with tumors of T1b stage and high RENAL scores (> 8), total ischemia was eventually used in order to control bleeding. According to CT angiography, these patients had more or equal 2 branches of renal artery, supplying the tumor. Mean operation time, volume of blood loss and warm ischemia time were 130.0+/-35 min, 185.0+/-80.0 ml and 14.0+/-3.2 min, respectively. In one case, there was an injury to the renal vein, which was sutured. Postoperative complications were observed in 5 (12.0%) patients. The glomerular filtration rate pre- and postoperatively was 76.5 and 72.0 ml/min/1.73 m2, and its decrease 1 month after RAPN was not significant (p>0.05).
CONCLUSION
Preoperative evaluation of renal arterial anatomy allows to detect the segmental branch that supplies the tumor. By its clamping, it is possible to perform efficient and safe robot-assisted partial nephrectomy without total ischemia.
Topics: Female; Humans; Ischemia; Male; Middle Aged; Nephrectomy; Renal Artery; Robotics; Treatment Outcome
PubMed: 35274860
DOI: No ID Found -
International Journal of Molecular... Apr 2024Heart transplantation with donation after circulatory death (DCD) provides excellent patient outcomes and increases donor heart availability. However, unlike... (Review)
Review
Heart transplantation with donation after circulatory death (DCD) provides excellent patient outcomes and increases donor heart availability. However, unlike conventional grafts obtained through donation after brain death, DCD cardiac grafts are not only exposed to warm, unprotected ischemia, but also to a potentially damaging pre-ischemic phase after withdrawal of life-sustaining therapy (WLST). In this review, we aim to bring together knowledge about changes in cardiac energy metabolism and its regulation that occur in DCD donors during WLST, circulatory arrest, and following the onset of warm ischemia. Acute metabolic, hemodynamic, and biochemical changes in the DCD donor expose hearts to high circulating catecholamines, hypoxia, and warm ischemia, all of which can negatively impact the heart. Further metabolic changes and cellular damage occur with reperfusion. The altered energy substrate availability prior to organ procurement likely plays an important role in graft quality and post-ischemic cardiac recovery. These aspects should, therefore, be considered in clinical protocols, as well as in pre-clinical DCD models. Notably, interventions prior to graft procurement are limited for ethical reasons in DCD donors; thus, it is important to understand these mechanisms to optimize conditions during initial reperfusion in concert with graft evaluation and re-evaluation for the purpose of tailoring and adjusting therapies and ensuring optimal graft quality for transplantation.
Topics: Humans; Heart Transplantation; Organ Preservation; Tissue and Organ Procurement; Animals; Perfusion; Tissue Donors; Energy Metabolism
PubMed: 38673737
DOI: 10.3390/ijms25084153 -
BJU International Aug 2023To provide a more rigorous assessment of factors affecting functional recovery after partial nephrectomy (PN) using novel tools that allow for analysis of more patients...
OBJECTIVES
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.
PATIENTS AND METHODS
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.
RESULTS
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.
CONCLUSIONS
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.
Topics: Humans; Kidney Neoplasms; Nephrectomy; Kidney; Warm Ischemia; Ischemia; Glomerular Filtration Rate; Retrospective Studies
PubMed: 37017637
DOI: 10.1111/bju.16023 -
Frontiers in Molecular Biosciences 2022Ischemic acute kidney injury (AKI) has always been a hot and difficult research topic in the field of renal diseases. This study aims to illustrate the safe warm...
Ischemic acute kidney injury (AKI) has always been a hot and difficult research topic in the field of renal diseases. This study aims to illustrate the safe warm ischemia time of kidney and the molecular network characteristics and pathological features of mild to severe ischemia reperfusion kidney injury. We established varying degrees of renal injury due to different ischemia time (0 min, 16 min, 18 min, 20 min, 22 min, 24 min, 26 min, 28 min, and 30 min) on unilateral (left kidney) ischemia-reperfusion injury and contralateral (right kidney) resection (uIRIx) mouse model. Mice were sacrificed 24 h after uIRIx, blood samples were harvested to detect serum creatinine (Scr), and kidney tissue samples were harvested to perform Periodic Acid-Schiff (PAS) staining and RNA-Seq. Differentially expressed genes (DEGs) were identificated, time-dependent gene expression patterns and functional enrichment analysis were further performed. Finally, qPCR was performed to validated RNA-Seq results. Our results indicated that there was no absolute safe renal warm ischemia time, and every minute of ischemia increases kidney damage. Warm ischemia 26min or above in mice makes severe kidney injury, renal pathology and SCr were both significantly changed. Warm ischemia between 18 and 26 min makes mild kidney injury, with changes in pathology and renal molecular expression, while SCr did not change. No obvious pathological changes but significant differences in molecular expression were found less than 16min warm ischemia. There are two key time intervals in the process of renal ischemia injury, 0 min-16 min (short-term) and 26 min-28 min (long-term). Gene expression of immune-related pathways were most significantly down-regulated in short-term ischemia, while metabolism-related pathways were the mainly enriched pathway in long-term ischemia. Taken together, this study provides novel insights into safe renal artery occlusion time in partial nephrectomy, and is of great value for elucidating molecular network characteristics and pathological features of mild to severe ischemia reperfusion kidney injury, and key genes related to metabolism and immune found in this study also provide potential diagnostic and therapeutic biomarkers for AKI.
PubMed: 36465563
DOI: 10.3389/fmolb.2022.1006917 -
Liver Transplantation : Official... Sep 2019The use of donation after circulatory death (DCD) liver allografts has been constrained by limitations in the duration of donor warm ischemia time (DWIT), donor agonal...
The use of donation after circulatory death (DCD) liver allografts has been constrained by limitations in the duration of donor warm ischemia time (DWIT), donor agonal time (DAT), and cold ischemia time (CIT). The purpose of this study is to assess the impact of longer DWIT, DAT, and CIT on graft survival and other outcomes in DCD liver transplants. The Scientific Registry of Transplant Recipients was queried for adult liver transplants from DCD donors between 2009 and 2015. Donor, recipient, and center variables were included in the analysis. During the study period, 2107 patients underwent liver transplant with DCD allografts. In most patients, DWIT and DAT were <30 minutes. DWIT was <30 minutes in 1804 donors, between 30 and 40 minutes in 248, and >40 minutes in 37. There was no difference in graft survival, duration of posttransplant hospital length of stay, and readmission rate between DCD liver transplants from donors with DWIT <30 minutes and DWIT between 30 and 40 minutes. Similar outcomes were noted for DAT. In the multivariate analysis, DAT and DWIT were not associated with graft loss. The predictors associated with graft loss were donor age, donor sharing, CIT, recipient admission to the intensive care unit, recipient ventilator dependence, Model for End-Stage Liver Disease score, and low-volume transplant centers. Any CIT cutoff >4 hours was associated with increased risk for graft loss. Longer CIT was also associated with a longer posttransplant hospital stay, higher rate of primary nonfunction, and hyperbilirubinemia. In conclusion, slightly longer DAT and DWIT (up to 40 minutes) were not associated with graft loss, longer posttransplant hospitalization, or hospital readmissions, whereas longer CIT was associated with worse outcomes after DCD liver transplants.
Topics: Adult; Aged; Cold Ischemia; Donor Selection; End Stage Liver Disease; Female; Follow-Up Studies; Graft Rejection; Graft Survival; Hospital Mortality; Humans; Length of Stay; Liver Transplantation; Male; Middle Aged; Patient Readmission; Registries; Time Factors; Warm Ischemia; Young Adult
PubMed: 30912253
DOI: 10.1002/lt.25453 -
Kidney International May 2024Prolonged warm ischemic is the main cause discarding donated organs after cardiac death. Here, we identified that prolonged warm ischemic time induced disseminated...
Prolonged warm ischemic is the main cause discarding donated organs after cardiac death. Here, we identified that prolonged warm ischemic time induced disseminated intravascular coagulation and severe capillary vasospasm after cardiac death of rat kidneys. Additionally, we found a significant accumulation of fibrinogen in a hypoxic cell culture of human umbilical vein epithelial cells and in isolated kidneys exposed to prolonged warm ischemic following flushing out of blood. However, pre-flushing the kidney with snake venom plasmin in a 90-minute warm ischemic model maximized removal of micro thrombi and facilitated the delivery of oxygen and therapeutic agents. Application of carbon monoxide-releasing CORM-401 during ex vivo hypothermic oxygenated perfusion achieved multipath protective effects in prolonged warm ischemic kidneys. This led to significant improvements in perfusion parameters, restoration of the microcirculation, amelioration of mitochondrial injury, oxidative stress, and apoptosis. This benefit resulted in significantly prolonged warm ischemic kidney recipient survival rates of 70%, compared with none in those receiving ex vivo hypothermic oxygenated perfusion alone. Significantly, ex vivo hypothermic oxygenated perfusion combined with cytoprotective carbon monoxide releasing CORM-401 treatment meaningfully protected the donated kidney after cardiac death from ischemia-reperfusion injury by reducing inflammation, oxidative stress, apoptosis, and pathological damage. Thus, our study suggests a new combination treatment strategy to potentially expand the donor pool by increasing use of organs after cardiac death and salvaging prolonged warm ischemic kidneys.
PubMed: 38789038
DOI: 10.1016/j.kint.2024.04.018 -
International Braz J Urol : Official... 2021To quantitatively evaluate the possible long-term protective effects of quercetin during renal warm ischemia.
PURPOSE
To quantitatively evaluate the possible long-term protective effects of quercetin during renal warm ischemia.
MATERIALS AND METHODS
Male rats were allocated into 4 groups: sham (S), sham quercetin (SQ), ischemia (I), and ischemia quercetin (IQ). Groups SQ and IQ received quercetin (50mg/kg) before and after surgery. Groups I and IQ had their left renal vessels clamped for 60 minutes. All animals were euthanized four weeks after the procedure, and serum urea and creatinine levels were measured. Renal weight and volume, cortex-non-cortex area ratio (C-NC), cortical volume (CV), glomerular volumetric density (Vv[glom]), volume-weighted glomerular volume (VWGV) and number of glomeruli per kidney (N[glom]) were evaluated by stereological methods. Results were considered statistically significant when p < 0.05.
RESULTS
Serum urea levels in group I increased by 10.4% in relation to group S, but no differences were observed among the other groups. The C-NC of group I was lower than those of all other groups, and group IQ had similar results to sham groups. The Vv[glom] and N[glom] of group I were lower than those of group S (33.7% and 28.3%, respectively) and group IQ had no significant difference compared to the S group.
CONCLUSIONS
Quercetin was effective as a nephroprotective agent in preventing the glomerular loss observed when the kidney was subjected to warm ischemia. This suggests that this flavonoid may be used preventively in kidney surgery, when warm ischemia is necessary, such as partial nephrectomy.
Topics: Animals; Kidney; Kidney Glomerulus; Male; Nephrectomy; Quercetin; Rats; Rodentia; Warm Ischemia
PubMed: 33848072
DOI: 10.1590/S1677-5538.IBJU.2020.0358 -
Transplantation Aug 2020Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest.... (Review)
Review
Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest. Despite the large potential for uDCD, programs of this kind only exist in a reduced number of countries with a limited activity. Barriers to uDCD are of a logistical and ethical-legal nature, as well as arising from the lack of confidence in the results of transplants from uDCD donors. The procedure needs to be designed to reduce and limit the impact of the prolonged warm ischemia inherent to the uDCD process, and to deal with the ethical issues that this practice poses: termination of advanced cardiopulmonary resuscitation, extension of advanced cardiopulmonary resuscitation beyond futility for organ preservation, moment to approach families to discuss donation opportunities, criteria for the determination of death, or the use of normothermic regional perfusion for the in situ preservation of organs. Although the incidence of primary nonfunction and delayed graft function is higher with organs obtained from uDCD donors, overall patient and graft survival is acceptable in kidney, liver, and lung transplantation, with a proper selection and management of both donors and recipients. Normothermic regional perfusion has shown to be critical to achieve optimal outcomes in uDCD kidney and liver transplantation. However, the role of ex situ preservation with machine perfusion is still to be elucidated. uDCD is a unique opportunity to improve patient access to transplantation therapies and to offer more patients the chance to donate organs after death, if this is consistent with their wishes and values.
Topics: Allografts; Donor Selection; Graft Rejection; Health Services Accessibility; Heart Arrest; Humans; Organ Preservation; Organ Transplantation; Perfusion; Resuscitation; Treatment Outcome; Warm Ischemia
PubMed: 32732830
DOI: 10.1097/TP.0000000000003139 -
Central European Journal of Urology 2024The aim of this review was to assess the outcomes of partial nephrectomy using indocyanine green (ICG) regarding ischemia time, positive surgical margins (PSM),... (Review)
Review
INTRODUCTION
The aim of this review was to assess the outcomes of partial nephrectomy using indocyanine green (ICG) regarding ischemia time, positive surgical margins (PSM), estimated blood loss (EBL) and estimated GFR reduction while also suggesting the optimal dosage scheme.
MATERIAL AND METHODS
A systematic review was performed using Medline (PubMed), ClinicalTrials.gov, and Cochrane Library (CENTRAL) databases, in concordance with the PRISMA statement. Studies in English regarding the use of indocyanine green in partial nephrectomy were reviewed. Reviews and meta-analyses, editorials, perspectives, and letters to the editors were excluded.
RESULTS
Individual ICG dose was 5 mg in most of the studies. The mean warm ischemia time (WIT) on each study ranged from 11.6 minutes to 27.2 minutes. The reported eGFR reduction ranged from 0% to 15.47%. Lowest mean EBL rate was 48.2 ml and the highest was 347 ml. Positive surgical margin rates were between 0.3% to 11%.
CONCLUSIONS
Indocyanine green seems to be a useful tool in partial nephrectomy as it can assist surgeons in identifying tumor and its related vasculature. Thereby, warm ischemia time can be reduced and, in some cases, selective ischemia can be implemented leading to better renal functional preservation.
PubMed: 38645804
DOI: 10.5173/ceju.2023.155 -
Annals of Vascular Surgery Feb 2022Renal artery aneurysms are a rare condition; however, the rate of diagnosis has been increasing, because of the increasing use of complementary diagnostic methods. The...
OBJECTIVE
Renal artery aneurysms are a rare condition; however, the rate of diagnosis has been increasing, because of the increasing use of complementary diagnostic methods. The best treatment strategy for RAAs remains controversial. Data on ex-vivo surgery associated with kidney autotransplantation are scarce. As a result, the goal of this study was to describe this technique and to report our results.
METHODS
A retrospective monocentric study was undertaken using the clinical records and images of 35 patients diagnosed with renal artery aneurysm from 01/01/2010 to 31/12/2018. Indications for ex vivo surgery and autotransplantation were complex aneurysms with diameter >20 mm or rapid growth or symptomatic aneurysms or women wishing to become pregnant. Complex aneurysms were defined by anatomical criteria (bifurcation of the renal artery and its primary branches or hilar aneurysms) and/or physiological criteria (when time of warm ischemia in in-situ reconstruction is expected to last more than 45 minutes). The technique of ex-vivo surgery and autotransplantation consists of performing a nephrectomy, renal cooling, treatment of aneurysm in banking and implantation of the kidney in the homolateral iliac fossa.
RESULTS
A total of 35 patients with 56 renal artery aneurysms (26 women, mean age 52.4 years-minimum and maximum 16 and 74 years) were included. Of these, 27 were treated by surgery and 8 were followed clinically. Among those treated surgically, 24 performed ex vivo surgery associated with autotransplantation. Regarding ex vivo surgery, nephrectomy was performed by laparoscopic surgery in 24 of the 27 surgeries, the mean surgical time was 5.3 hours, the median warm ischemia time was 4 minutes and the length of hospital stay was 12.2 days. Mortality was 0% and the kidney patency rate was 93% with a follow up of 47.2 months. Of the 17 patients with hypertension, 6 cured it, 4 improved and 7 maintained hypertension.
CONCLUSION
Kidney autotransplantation appears to be efficient for most complex RAA with the possibility to minimize surgical aggression by performing laparoscopic nephrectomy.
Topics: Adolescent; Adult; Aged; Aneurysm; Female; Humans; Kidney Transplantation; Laparoscopy; Male; Middle Aged; Nephrectomy; Operative Time; Postoperative Complications; Renal Artery; Replantation; Retrospective Studies; Risk Factors; Time Factors; Transplantation, Autologous; Treatment Outcome; Warm Ischemia; Young Adult
PubMed: 34656716
DOI: 10.1016/j.avsg.2021.07.048