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References in periodicals archive ?
Multivariate logistic regression analysis revealed that donor hypertension (odds ratio [OR]: 1.43, 95% confidence interval [CI]: 1.02-2.06, P = 0.035), donor terminal serum creatinine (OR: 1.27, 95% CI: 1.06-1.62, P = 0.023), warm ischemic time (OR: 3.45, 95% CI: 1.97-6.37, P = 0.002), and terminal resistance (OR: 3.12, 95% CI: 1.76-6.09, P = 0.012) were independent predictors of DGF.
There were no significant differences between these two groups with respect to donor and recipient age, duration of pretransplant dialysis, positivity for panel-reactive antibody, number of HLA mismatches, cold ischemic time, warm ischemic time (determined from the beginning of heartbeat to the start of perfusion), primary diseases in recipients, causes of death of donors, sCr levels, body mass index, and DCD Maastricht categories (all P > 0.05).{Table 1}
Multivariate logistic regression analysis revealed four significant risk factors for DGF, including donor hypertension history (odds ratio [ OR ]: 1.43, 95% confidence interval [ CI ]: 1.02-2.06, P = 0.035), donor terminal sCr ( OR : 1.27, 95% CI : 1.06-1.62, P = 0.023), warm ischemic time ( OR : 3.45, 95% CI : 1.97-6.37, P = 0.002), and terminal vascular resistance ( OR : 3.12, 95% CI : 1.76-6.09, P = 0.012) [Table 4].
nephrometry score has shown its prognostic capability with respect to postoperative outcomes, such as reducing warm ischemic time and reducing surgery-related complications.[sup.7,8] However, there is some debate on whether it can predict renal functional outcomes and surgery-related outcomes.[sup.6,9]-[sup.11] Moreover, these studies mostly applied to the patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN), minimally invasive surgeries that used warm ischemia methods.
Hayn and colleagues concluded that a higher nephrometry score was significantly associated with an increased warm ischemic time in their LPN case series.[sup.17] In their RPN series, Png and colleagues showed that complex tumours with a higher nephrometry scores had significantly high ischemic times compared with non-complex tumours.[sup.11] In their minimally invasive PN case series, Liu and colleagues[sup.18] and Altunrende and colleagues[sup.9] found that nephrometry score was predictive of warm ischemic time, and mean warm ischemic time increased significantly by tumour complexity.
Early organ function could be compromised with DCD transplantation due to a prolonged warm ischemic time associated with withdrawal of life support, the subsequent declaration of cardiac death, and the time of cannulation for flushing and cooling.
Traditionally, 30 minutes was defined as the threshold for renal warm ischemic time (WIT) in open surgery.[sup.1,2] However, reports show renal function recovery at WIT of 45 to 271 minutes.[sup.3]-[sup.6]
Warm ischemic time is important for the preservation of renal function, with duration of vessel clamping previously found to be an independant predictor of renal insufficiency.[sup.12] A previous study has shown this to be particularly important in patients with pre-existing renal impairment and elderly patients.[sup.4] Our results demonstrate excellent short-term preservation of renal function in elderly patients particularly at risk for renal failure.
Studies have addressed the technical aspects of partical nephrectomy, particularly the impact of ischemic time on renal function.[sup.1,3,4] Partial nephrectomy is commonly performed with renal artery occlusion to control bleeding.[sup.5] Warm ischemic times are ideally kept less than 20 to 30 minutes; use of ice slush to create cold ischemic conditions extends the target time to less than 35 to 55 minutes.[sup.3,6] The use of manual compression of the kidney without vascular occlusion is also reported in the literature.[sup.7] While manual compression avoids any potential vascular pedicle injury, its effect on renal function and recovery is not well-studied.[sup.3,6,7] However, this technique may not be done with a laparoscopic partial nephrectomy.
Controlled donors represented donors from intensive therapy/high-dependency unit referrals (withdrawal of treatment); these donors had reduced primary warm ischemic times (WITs).
In their article, Moser and colleagues review what is arguably Canada's longest single-centre experience with this high-risk transplant.[sup.7] This group demonstrates an evolving DCD program, with improvements in procedural tasks during procurement and subsequent reduction in warm ischemic times. Machine pulsatile perfusion efforts were recruited with increasing frequency as the program developed with what appears to be an impact on improving early graft function, although rates of delayed graft function (DGF; need for dialysis in the first week post-transplantation) did not change significantly (59%-71%).