孤立肾模型中热缺血时间对肾部分切除术后长期肾功能的影响

Effect of warm ischemia time on long-term postoperative renal function after partial nephrectomy in solitary kidney

目的：热缺血时间对肾部分切除术后肾功能的影响仍然存在争议,探讨热缺血时间对肾部分切除术后长期肾功能的影响.方法：回顾性研究海德堡大学医学院泌尿外科1984年8月~2011年7月收治75名孤立肾患者实施的83例肾部分切除术,评估热缺血时间、术前肾功能基线水平、切除的正常肾组织体积对术后长期肾功能水平和变化的影响.结果：平均术前肾功能57.41 ml/mi n per 1.73 m2,平均热缺血时间为18.04 mi n ,平均切除的正常肾组织体积为18.79 c m3,平均随访时间69.39个月.多因素分析不同术前肾功能基线水平的各组在术后12个月时差异有统计学意义(P ＝0.01)；围手术期的急性肾衰竭事件明显而持续影响术后的肾功能水平(12个月 P ＝0.001,60个月 P ＝0.03)；而热缺血时间各分组和切除的正常肾组织体积与术后肾功能水平无关联.围手术期急性肾衰竭事件在术后12个月时明显影响术后肾功能的变化(P ＜0.01),切除的正常肾组织体积各组在整个随访期均保持显著差异(12个月 P ＝0.03,36个月 P ＜0.01,60个月 P ＜0.01).结论：术前肾脏质量和术后肾脏的体积是最重要的术后长期肾功能危险因素,术前肾功能基线水平决定术后肾功能的水平,术后存留的肾脏体积决定术后肾功能恢复的能力；围手术期急性肾衰竭事件是新发现的术后长期肾功能的风险因子；热缺血时间虽然与术后长期肾功能无直接关联,但可以通过增加围手术期急性肾衰竭事件的风险间接影响术后肾功能的水平和恢复能力.

Objective:The effects of warm ischemia time on long-term renal function after partial nephrectomy remain controversial.Our aim was to evaluate the effect of warm ischemia time on long-term renal function after partial nephrectomy.Methods:A retrospective study was performed on 75patients undergoing 83procedures of partial nephrectomy in Department of Urology of Clinical Center of University Heidelberg from 08/1984to 07/2011.The effects of warm ischemia time,preoperative renal function and resected normal parenchyma volume on long-term renal function in patients with a solitary kidney were evaluated.Results:Mean preoperative eGFR was 57.41mL/(min per 1.73m2.Mean ischemia time was 18.04min.Mean volume of resected normal parenchyma was 18.79cm3.Mean follow-up time was 69.39months.On multivariable analysis,adjusting for age and comorbidities factors,preoperative renal function baseline was significantly associated with renal function at 12th month postoperation(P=0.01).Perioperative ARF event significantly affected postoperative renal function at 12th month on(P=0.001)and60th month(P=0.03)postoperation.Warm ischemia time and resected normal parenchyma volume were not risk factors of long-term postoperative renal function.The perioperative ARF event was significantly associated with renal function change at 12th month postoperation(P<0.01).Only resected volume of normal parenchyma was significantly associated with renal function change during whole follow-up period(P=0.03at 12th month,and P<0.01at 36th and 60th month).Conclusions:The quality and quantity of kidney were most important risk factors of longterm renal function after partial nephrectomy.The quality of preoperative kidney primarily determines long-term postoperative renal function.Additionally,the quantity of preserved functional parenchyma volume was the main determinant for long-term kidney recovery.Moreover,the acute renal failure was an independent risk factor influencing both recovery capacity and renal function level in long-term postoperative duration.Furthermore,WIT was indirectly associated with postoperative renal function leading to a higher rate of perioperative acute renal failure.