Surgical Renal Ischemia: A Contemporary Overview

Main Category: Urology / Nephrology
Article Date: 19 Jul 2008 - 0:00 PDT

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UroToday.com - The topic of warm ischemic kidney injury has received renewed attention given the increased use of partial nephrectomy (PN) for renal cell carcinoma. Contemporary data in the PN literature support that warm ischemia time of 30 minutes or less is associated with minimal kidney injury. Surprisingly, there is no rigorous scientific data to support this widely accepted 30 minute time limit. Additionally, a standardized time limit cannot be generalized to all patients as nearly a third have chronic kidney disease (CKD) prior to intervention, and these patients are at a substantially higher risk of kidney injury as the result of warm ischemia. There is currently a great need to devise diagnostic and therapeutic measures to aid in prevention of postoperative kidney injury in these patients.

Our review of surgical renal ischemia was conducted with several goals in mind. The first was to examine the laboratory and clinical data that support currently accepted time limits for warm ischemia tolerance for normal kidneys. Animal and human clinical studies were reviewed, and their relevance to current practice was assessed. The second goal was to better define safe limits for warm ischemia specifically for PN. Contemporary clinical data support that age, prolonged warm ischemia time >30 minutes, and pre-existing CKD are risk factors for postoperative kidney injury. The third goal was to assess how various commonly utilized surgical techniques may impact postoperative kidney function. The fourth goal was to review current advances in the fields of nephrology and renal physiology, and how these advances may play a future role in clinical practice.

Measures are discussed that may improve management of patients before and after PN including use of GFR measurement in lieu of serum creatinine to monitor kidney function. Emerging preventative strategies, diagnostic markers, and therapeutic strategies are also discussed. It is our hope that the review will provide urologists with a clearer understanding of the pathophysiology of ischemic kidney injury. We also hope that it reinforces the central importance of this topic to stimulate both increased research funding and activity.

Written by Matthew Simmons, MD, as part of Beyond the Abstract on UroToday.com.

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