Renal and major clinical outcomes and their determinants after nephrectomy in patients with pre-existing chronic kidney disease: A retrospective cohort study.

The consequences of partial nephrectomy (PN) compared to radical nephrectomy (RN) are less documented in patients with pre-existing chronic kidney disease (CKD) or with solitary kidney (SK). We assessed renal outcomes, and their determinants, after PN or RN in a retrospective cohort of patients with moderate-to-severe CKD (RN-CKD and PN-CKD) or SK (PN-SK). All surgical procedures conducted between 2013 and 2018 in our institution in patients with pre-operative estimated glomerular filtration rate (eGFR)<60 mL/min/1.73m2 or with SK were included. The primary outcome was a composite criterion including CKD progression or major adverse cardio-vascular events (MACE) or death, assessed one year after surgery. Predictors of the primary outcome were determined using multivariate analyses. A total of 173 procedures were included (67 RN, and 106 PN including 27 SK patients). Patients undergoing RN were older, with larger tumors. Preoperative eGFR was not significantly different between the groups. One year after surgery, PN-CKD was associated with lower rate of the primary outcome compared to RN-CKD (43% vs 71% p = 0.007). In multivariate analysis, independent risk factors for the primary outcome were postoperative AKI (stage 1 to stage 3 ranging from OR = 8.68, 95% CI 3.23-23.33, to OR = 28.87, 95% CI 4.77-167.61), larger tumor size (OR = 1.21 per cm, 95% CI 1.02-1.45), while preoperative eGFR, age, sex, diabetes mellitus, and hypertension were not. Postoperative AKI after PN or RN was the major independent determinant of worse outcomes (CKD progression, MACE, or death) one year after surgery.

Any reduction in maternal kidney mass makes a difference during pregnancy in gestational and fetal outcome.

Little is known about the effect tubulointerstitial nephropathies have in modulating maternal-fetal outcomes in pregnancy. Therefore, we analyzed the main outcomes of pregnancy in these women to gain a better understanding of the role of a reduction in maternal kidney mass. From the Torino Cagliari Observational Study (TOCOS) cohort, we selected 529 patients with a diagnosis of tubulointerstitial disease and focused on 421 patients with chronic kidney disease (CKD) stage 1, without hypertension but with proteinuria less than 0.5 g/day at referral. From a cohort of 2969 singleton deliveries from low-risk pregnancies followed in the same settings we selected a propensity score matched control cohort of 842 pregnancies match 2:1 for age, parity, body mass index, ethnicity, and origin. Time to delivery was significantly shorter in the study cohort 38.0 (Quartile 1-Quartile 3: 37.0-39.0) versus 39.0 (Q1-Q3 38.0-40.0) weeks, with respect to controls. Incidence of delivery of less than 37 gestational weeks significantly increased from controls (7.4%) to women with previous acute pyelonephritis (10.8%), other tubulointerstitial diseases (9.7%) and was the highest in patients with a single kidney (31.1%). Similarly, neonatal birthweight significantly and progressively decreased from controls (3260 g [Q1-Q3: 2980-3530]), previous acute pyelonephritis (3090 g [Q1-Q3: 2868-3405], other tubulointerstitial diseases (3110 g [Q1-Q3: 2840-3417]), and to solitary kidney (2910 g [Q1-Q3: 2480-3240]). Risk of developing preeclampsia was significantly higher in the CKD cohort (3.6% vs 1.7% in low-risk controls). Thus, even a small reduction in functional kidney mass, such as a pyelonephritic scar, is associated with a shorter duration of pregnancy and an increased risk of preterm delivery. The risk is proportional to the extent of parenchymal reduction and is highest in cases with a solitary kidney.

Renal Function After CT-Guided Cryoablation of Small Renal Tumours in Patients with Solitary Kidney: An Analysis of European Multinational Prospective EuRECA Registry.

PURPOSE: Treatment of renal cell carcinoma (RCC) in patients with solitary kidneys remains challenging. The purpose of this multicentre cohort study was to explore how renal function is affected by percutaneous image-guided cryoablation in patients with solitary kidneys. MATERIAL AND METHODS: Data from the European Registry for Renal Cryoablation database were extracted on patients with RCC in solitary kidneys treated with image-guided, percutaneous cryoablation. Patients were excluded if they had multiple tumours, had received previous treatment of the tumour, or were treated with more than one cryoablation procedure. Pre- and post-treatment eGFR (within 3 months of the procedure) were compared. RESULTS: Of 222 patients with solitary kidneys entered into the database, a total of 70 patients met inclusion criteria. The mean baseline eGFR was 55.8 ± 16.8 mL/min/1.73 m2, and the mean 3-month post-operative eGFR was 49.6 ± 16.5 mL/min/1.73 m2. Mean eGFR reduction was - 6.2 mL/min/1.73 m2 corresponding to 11.1% (p = 0.01). No patients changed chronic kidney disease group to severe or end-stage chronic kidney disease (stage IV or V). No patients required post-procedure dialysis. CONCLUSION: Image-guided renal cryoablation appears to be safe and effective for renal function preservation in patients with RCC in a solitary kidney. Following cryoablation, all patients had preservation of renal function without the need for dialysis or progression in chronic kidney disease stage despite the statistically significant reduction in eGFR. LEVEL OF EVIDENCE 3: Observational study.

A renal aplasia case mimicking radiologically as unilateral renal agenesis in a child with spina bifida, atresia ani and unilateral undescended testis: a case report.

BACKGROUND: As a result of the failure of embryogenic kidney formation, a condition can occur where not a single kidney appears and this phenomenon is known as unilateral renal agenesis (URA). Both aplastic and dysplastic kidney are different from renal agenesis, atrophy and renal hypoplasia. However, from this case report it can be seen that there are similarities, both radiologically and macroscopically, between cases of unilateral renal aplasia and renal agenesis. CASE PRESENTATION: A 2 year old Javanese boy came to the health facility with complaints of recurrent fever and urinary tract symptoms such as dysuria and straining. Computerized Tomography (CT) scan of the abdomen and urography showed agenesis of the left kidney and a probable spina bifida. Cystourethrography examination was done and showed grade 5 voiding, then retrograde pyelography was performed with the diagnosis of unilateral renal agenesis was made because there was no visible left side collecting system even though there was a duplication in the left ureter. The next examination was carried out by histopathology and immunohistochemistry after resection of the left side of the ureter and the diagnosis increasingly pointed towards renal aplasia after primitive renal structures were found. CONCLUSIONS: Renal agenesis and aplastic kidney are difficult to differentiate macroscopically and radiologically. Nevertheless, from this case report, we try to provide some interesting points to differentiate cases of unilateral renal agenesis from Renal Dysplasia which presents as unilateral renal aplasia.

Application of ultrasound-guided percutaneous nephrostomy in the treatment of a solitary kidney with hydronephrosis due to renal tuberculosis.

PURPOSE: To investigate the value of ultrasound-guided percutaneous nephrostomy and nephrostomy tube replacement for treating a solitary kidney with hydronephrosis due to renal tuberculosis. METHODS: Clinical data of patients with a solitary kidney with hydronephrosis caused by renal tuberculosis who underwent ultrasound-guided percutaneous nephrostomy in our hospital from January 2011 to December 2022 were retrospectively analyzed. The associated success rate and complications were statistically analyzed, pre- and post-catheterization changes in serum creatinine and blood urea nitrogen levels were compared, success rate and complications of nephrostomy tube replacement in patients with long-term catheterization were statistically analyzed, and the impact of long-term catheterization on patient life was investigated. RESULTS: Overall, 32 patients aged 17-75 years (average age: 44.1 ± 16.9 years) underwent ultrasound-guided percutaneous nephrostomy. Sixty-three punctures were performed; the puncture success rate was 100%. The levels of serum creatinine and blood urea nitrogen of patients decreased after catheterization, and the differences between the pre-catheterization and post-catheterization were significant (P < 0.05). There were 1, 3, and 12 cases of serious, minor, and fistula-related complications, respectively. The mean duration of the indwelling catheter was 56.7 ± 36.2 (range, 13-120) months. The number of nephrostomy tube replacements was 344 times, and the success rate was 100%. All patients could take care of the puncture point by themselves. CONCLUSION: Ultrasound-guided percutaneous nephrostomy and nephrostomy tube replacement have a high success rate and few complications, which can improve the renal function of patients. It is of great value for treating a solitary kidney with hydronephrosis caused by renal tuberculosis.

Functional recovery after partial nephrectomy in a solitary kidney.

OBJECTIVES: Partial nephrectomy (PN) is the reference standard for renal mass in a solitary kidney (RMSK), although factors determining functional recovery in this setting remain poorly defined. PATIENTS/METHODS: Single center, retrospective analysis of 841 RMSK patients (1975-2022) managed with PN with functional data, including 361/435/45 with cold/warm/zero ischemia, respectively. A total of 155 of these patients also had necessary studies for detailed analysis of parenchymal volume preserved. Acute kidney injury (AKI) was classified by RIFLE (Risk/Injury/Failure/Loss/Endstage). Recovery-from-ischemia (Rec-Ischemia) was defined as glomerular filtration rate (GFR) saved normalized by parenchymal volume saved. Logistic regression identified predictive factors for AKI and predictors of Rec-Ischemia were analyzed by multivariable linear regression. RESULTS: Overall, median preoperative GFR was 56.7 ml/min/1.73m2 and new-baseline and 5-year GFRs were 43.1 and 44.5 ml/min/1.73m2, respectively. Median follow-up was 55 months; 5-year dialysis-free survival was 97%. In the detailed analysis cohort, a primary focus of this study, median warm (n = 70)/cold (n = 85) ischemia times were 25/34 minutes, respectively; and median preoperative, new-baseline and 5-year GFRs were 57.8, 45.0, and 41.7 ml/min/1.73m2, respectively. Functional recovery correlated strongly with parenchymal volume preserved (r = 0.84, p < 0.001). Parenchymal volume loss accounted for 69% of the total median GFR decline associated with PN, leaving only 3 to 4 ml/min/1.73m2 attributed to ischemia and other factors. AKI occurred in 52% of patients and the only independent predictor of AKI was ischemia time. Independent predictors of reduced Rec-Ischemia were increased age, warm ischemia, and AKI. CONCLUSION: The main determinant of functional recovery after PN in RMSK is parenchymal volume preservation. Type/duration of ischemia, AKI, and age also correlated, although altogether their contributions were less impactful. Our findings suggest multiple opportunities for optimizing functional outcomes although preservation of parenchymal volume remains predominant. Long-term function generally remains stable with dialysis only occasionally required.

2022 Recommendations of the AFU Lithiasis Committee: Specific cases - chronic kidney disease, bilateral stones, and solitary kidney.

Chronic kidney disease, diabetes and hypertension are risk factors of kidney function impairment. The relative risk of kidney failure is 1.52 in patients with urinary stone disease. The various techniques used to remove upper urinary tract stones generally do not alter kidney function in patients with normal kidney function and may sometimes improve kidney function or slow its deterioration in patients with kidney disease. Compared to the asynchronous treatment of bilateral renal and ureteral stones, concomitant treatment is associated with higher risk of anuria and the need of additional interventions, in the absence of postoperative stenting. For the treatment of solitary kidney stones, the absence of postoperative stenting increases the risk of postoperative anuria. Moreover, the multiplication of percutaneous nephrolithotomy access tracts increases the risk of bleeding and that of kidney function impairment. METHODOLOGY: These recommendations were developed according to two methods: the Clinical Practice Recommendations (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and their adaptability to the French context.

Screening for Zinner Syndrome in Patients With a Congenitally Solitary Kidney: Lessons Learned.

PURPOSE: We determined if serial screening ultrasounds are beneficial in evaluating for the development of Zinner syndrome in males with a congenital solitary kidney. MATERIALS AND METHODS: All patients included had their congenital solitary kidney diagnosed at <20 years of age and had to be ≥20 at their last visit. Individuals were seen annually, with pelvic ultrasounds to screen for mesonephric duct cysts obtained at birth and every year of age, divisible by 5. RESULTS: At a median follow-up of 38 years of age (range 20-57), 17% (20/121) developed Zinner syndrome, with 60% (12/20) developing clinical symptoms. The yield for screening ultrasound studies was significantly higher in patients ≤20 years of age at 3.5% (12/340), compared to 0.33% (1/296) in patients >20 years of age (P = .004). Serial ultrasounds reveal the onset of lower urinary tract and cyst-related pain symptoms are associated with the growth of the seminal vesicle cyst to ≥5 cm (P = .0198). Of symptomatic patients, 75% (8/12) had abnormal uroflows. Complete urodynamic studies revealed findings consistent with bladder outlet obstruction in 38% (3/8), equivocal for obstruction in 24% (2/8), and detrusor underactivity in 38% (3/8). Cyst excision effectively resolved voiding symptoms that were obstructive in etiology but failed to resolve symptoms in patients with detrusor underactivity. CONCLUSIONS: Serial ultrasound evaluations reveal that cyst growth to ≥5 cm in size is highly related to the onset of clinical symptoms, with the resolution of voiding symptoms by cyst excision directly associated with urodynamic findings.

GFR measurements and ultrasound findings in 154 children with a congenital solitary functioning kidney.

BACKGROUND: Multicystic dysplastic kidney (MCDK) and unilateral renal agenesis (URA) are the most common reasons for a congenital solitary functioning kidney (SFK). We aimed to assess the presence of abnormalities in the congenital SFK and evaluate kidney function using chrome EDTA (CrEDTA) measurements. METHODS: We retrospectively reviewed the medical records of 154 children with MCDK and URA in the period from 2005 to 2022 to analyze results from ultrasound scans and CrEDTA glomerular filtration rate (GFR) examinations. RESULTS: Of 154 children with a solitary kidney due to MCDK (62%) or URA (38%), abnormalities on the congenital SFK were found in 13 children (8%). The abnormalities spontaneously resolved in 6 children (46%). The most common abnormality was hydronephrosis. Compensatory hypertrophy was found in 17% of the children within the first 6 months of life. 116 children (90%) had a standard GFR (sdGFR) above 75% of expected for the age. Out of those with a sdGFR below 75% of expected, 3 (23%) had abnormalities in the congenital SFK. There was no difference in sdGFR between children with MCDK and URA. CONCLUSIONS: Our study is the first using CrEDTA for GFR measurements and suggests that most children with a congenital SFK due to MCDK or URA have a kidney function within expected for the age. Compensatory hypertrophy of the SFK is found in a minority of children within the first six months of life, suggesting that this process is developing over time. The prevalence of abnormalities in the SFK seems low, however those with abnormalities (e.g. hydronephrosis) are at higher risk of reduced sdGFR.

Follow up of renal outcomes in children with solitary kidney.

BACKGROUND: Solitary kidney (SK) affects 1/1000 people worldwide, and there are controversies concerning renal outcomes in these patients. This study aimed to investigate clinical findings and renal outcomes in children with SK and to compare the results for congenital (CSK) and acquired SK (ASK) groups. METHODS: The study included patients that presented to our pediatric nephrology department with SK between January 2010 and January 2021. Demographic and clinical data were recorded retrospectively. RESULTS: Of the 101 patients with SK, 71 had CSK (55 had unilateral renal agenesis and 16 had a multicystic dysplastic kidney) and 30 had ASK (17 had previously undergone unilateral nephrectomy due to a renal tumor and 13 had urological structural anomalies). There were nine patients (9%) with renal injury. The serum uric acid level was significantly higher and the estimated glomerular filtration rate was significantly lower in the patients with ASK compared with those with CSK (p = 0.005 and p < 0.001, respectively). There was a positive correlation between renal injury and the uric acid level (p < 0.001, r = 0.45). CONCLUSION: In addition to the management of blood pressure and proteinuria, it is important to control uric acid levels in patients with SK, especially those with ASK, to prevent renal injury. The ASK group has a greater risk of renal injury than the CSK group. There is a need for new markers to predict early stage renal damage in SK.

Comprehensive Management of Renal Masses in Solitary Kidneys.

BACKGROUND: A renal mass in a solitary kidney (RMSK) has traditionally been managed with partial nephrectomy (PN), although radical nephrectomy (RN) is occasionally required. Most RMSK studies have focused on patients for whom PN was achieved. OBJECTIVE: To provide a comprehensive analysis of the management strategies/outcomes for an RMSK and address knowledge deficits regarding this challenging disorder. DESIGN, SETTING, AND PARTICIPANTS: A total of 1024 patients diagnosed with an RMSK (1975-2022) were retrospectively evaluated. Baseline characteristics and pathologic/functional/survival outcomes were analyzed. INTERVENTION: PN/RN/cryoablation (CA)/active surveillance (AS). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Functional outcomes, perioperative morbidity/mortality, and 5-yr recurrence-free survival (RFS) were evaluated. Kruskal-Wallis and chi-square tests were used to compare cohorts, and log-rank test and Cox proportional hazard model were used for survival analysis. RESULTS AND LIMITATIONS: Of 1024 patients, 842 underwent PN (82%), 102 CA (10%), 54 RN (5%), and 26 AS (3%). The median tumor size and RENAL([R]adius [tumor size as maximal diameter], [E]xophytic/endophytic properties of tumor, [N]earness of tumor deepest portion to collecting system or sinus, [A]nterior [a]/posterior [p] descriptor, and [L]ocation relative to polar lines) score were 3.7 cm and 8, respectively. The median follow-up was 53 mo. For PN, 95% were clamped, and the median warm and cold ischemia times were 22 and 45 min, respectively. For PN, the median preoperative glomerular filtration rate (GFR) was 57 ml/min/1.73 m2, and the median new baseline and 5-yr GFRs were 47 and 48 ml/min/1.73 m2, respectively. Dialysis-free survival for PN was 97% at 5 yr. Twenty-two (2.1%) patients with clear-cell renal cell carcinoma and RENAL score ≥10 (median = 11) received tyrosine kinase inhibitors (TKIs) to facilitate PN, leading to 57% median decrease of tumor volume; PN was accomplished in 20 (91%). Forty-one patients had planned RN (4.0%), most often due to severe pre-existing chronic kidney disease (CKD), and 13 were converted from PN to RN (1.5%). Clavien III-V perioperative complications were observed in 80 (8%) patients and 90-d mortality was 0.6%. Five-year RFS for PN, CA, and RN were 83%, 80%, and 72%, respectively (p = 0.03 for PN vs RN). CONCLUSIONS: Nephron-sparing approaches are feasible and successful in most RMSK patients. PN for an RMSK is often challenging but can be facilitated by selective use of TKIs. RN is occasionally required due to severe CKD, over-riding oncologic concerns, or conversion from PN. This is the first large RMSK study to provide a comprehensive analysis of all management strategies/outcomes. PATIENT SUMMARY: Kidney cancer in a solitary kidney is a major challenge for achieving cancer-free status and avoiding dialysis. Although partial nephrectomy is the principal treatment for a renal mass in a solitary kidney, other options are occasionally required to optimize outcomes.

Uncovering risk factors for kidney injury in children with a solitary functioning kidney.

Children with a solitary functioning kidney (SFK) have an increased risk of kidney injury. The exact risk of and risk factors for kidney injury remain unknown, which impedes personalized care. Here, we recruited a nationwide multicenter cohort of 944 patients with SFK to get more insight into this by consenting patients born in 1993-2020 and diagnosed with congenital or acquired SFK before adulthood. The median follow-up was 12.8 years and four indications of kidney injury were studied: urine protein-creatinine ratios, blood pressure, estimated glomerular filtration rate and use of anti-hypertensive/proteinuric medication. For each indicator except medication use, separate cut-off values for any injury and severe injury were used. Survival analyses indicated that at 18 years of age, any or severe kidney injury were present in 75% and 39% of patients with congenital SFK, respectively. Risk factors for kidney injury included kidney agenesis as cause of the SFK, anomalies in the SFK, and high body mass index at last follow-up. Kidney agenesis and being overweight were specifically associated with proteinuria and high blood pressure, whereas anomalies in the SFK were associated with reduced estimated glomerular filtration rates. The high prevalence of kidney injury in patients with SFK emphasizes the need for long-term follow-up, in which lifestyle is an important topic to address. More research into the etiological role of risk factors will help to translate our findings into individualized care strategies. Thus, our study shows that a significant proportion of children with SFK will develop kidney injury over time.

Congenital Solitary Functioning Kidney: A Review.

BACKGROUND: Solitary functioning kidney (SFK) is a subgroup of the Congenital Anomalies of the Kidneys and Urinary Tract (CAKUT). Although the prognosis of these patients was considered good in the past, numerous studies have shown different levels of kidney damage associated with this condition. Serum creatinine measurement is still the most used marker to assess renal function, even though the limitations are widely known. OBJECTIVE: The present review aims to summarize and update the scientific literature on congenital SFK, discussing its pathophysiology, diagnosis, complications, prognosis, role of novel urinary biomarkers, treatment, and follow-up. RESULTS: The natural history of congenital SFK is still an unresolved issue due to several factors. Although it has not yet been proven in humans, Brenner's hyperfiltration hypothesis is the most concrete theory to explain the poor renal outcomes of patients born with one functioning kidney. The search for novel urinary biomarkers capable of assessing renal function and predicting renal outcomes has already started, but there are still few studies on this specific population. Among the most studied markers, Cystatin C, EGF and NGAL have shown potential usefulness for the follow-up of these patients. The treatment still relies on the search for kidney injury and general renoprotective measures. CONCLUSION: Further research with a longer follow-up duration is needed to better understand the natural course of congenital SFK and the role of novel urinary biomarkers in this specific population. Thus, it will be possible to improve the prognosis of these patients.

Kidney length standardized to body length predicts outcome in infants with a solitary functioning kidney.

BACKGROUND: Infants with a solitary functioning kidney (SFK) are at risk for chronic kidney injury (CKI). Lack of compensatory kidney growth (CKG) is associated with CKI, but measuring CKG is challenging since it is typically reported relative to normal kidneys. This study aims to (1) standardize SFK growth in infants, (2) investigate the relationship between standardized kidney length and clinical outcomes, and (3) use these results to develop a risk-based prediction model and local clinical pathway for SFK care. METHODS: This was a quality improvement study of 166 infants with an SFK. Linear regression was used to assess kidney growth from 0 to 180 days of life. Univariate binary regression analysis was used to identify kidney length to body length thresholds associated with the development of CKI, defined as the composite outcome of chronic kidney disease (eGFR < 60 mL/min/1.73 m2), hypertension, or proteinuria. RESULTS: Kidneys grew in length from 0 to 180 days, and growth was constant when standardized to body length. Over follow-up, infants with a baseline kidney length to body length ≤ 0.088 were more likely to experience CKI than the rest of the cohort (27 vs. 8%, p = 0.04). Kidney length to body length ≤ 0.088 was also significantly associated with CKI development (OR 4.17, 95% CI 1.14-15.28, p = 0.04). CONCLUSIONS: In this study, kidney length to body length ratio was a stable CKG metric over 0-180 days, and a baseline ratio ≤ 0.088 was a risk factor for CKI. Results will aid in developing a practical, point-of-care risk assessment tool, and overarching risk-stratified clinical pathway for infants with an SFK. A higher resolution version of the Graphical abstract is available as Supplementary information.

[Functional state of a solitary kidney after nephrectomy for renal cancer].

INTRODUCTION: The outcome of surgical treatment of renal cancer depends not only on cancer-specific survival, but also on the degree of loss of renal function, which often develops after surgery, especially radical nephrectomy. AIM: To study the features of functional changes in a solitary kidney as a compensation mechanism after radical nephrectomy for renal cancer. MATERIALS AND METHODS: The functional state of a solitary kidney in 36 patients with renal cancer who undergone to radical nephrectomy was evaluated. There were 20 and 16 women. The mean age was 59.0+/-10.8 years (from 39 to 76 years). The size of the tumor was in the range of 7.0-12.0 cm. All patients with a solitary kidney underwent a follow-up examination 3 months after surgery, including measurement of peripheral blood pressure with calculation of mean dynamic pressure, renal ultrasound, calculation of glomerular filtration rate (GFR), renal doppler ultrasound, determination of serum fibrinogen and fibrin monomers, and microscopy of the bulbar conjunctiva. Patients who had pathological abnormalities during the examination were prescribed reno-cardioprotective drugs, including perindopril in a titrated dose, apixaban 5 mg a day as thromboprophylaxis and for improvement of the flow properties of blood for a period of 3 months with re-evaluation of the above parameters. RESULTS: In 61.1% of patients after radical nephrectomy, on 2-4 postoperative days, there was a tendency to increase blood pressure compared to baseline values (p<0.05). By the seventh day after the procedure, the volume of the contralateral kidney increased on average by 16% (from 110.4+/-11.2 cm3 to 132.4+/-4.8 cm3, p<0.05). After radical nephrectomy, a decrease in GFR was detected in 33 cases (91.7%; p<0.05). Renal doppler ultrasound showed a moderate increase in linear blood flow, the resistance index in the main renal artery, and a decrease in the pulse index in the segmental and arcuate arteries. The microscopy of the bulbar conjunctiva in 83.3% of patients revealed changes in the microcirculatory bed, including narrowing of arterioles, dilation of venules, a decrease in venular and capillary blood flow. After 3 months of reno-cardioprotective therapy, it was revealed that the target values of blood pressure (<130/85 mm Hg) were achieved with an average dynamic blood pressure of 93.4+/-2.6 mm Hg. In addition, a decrease in creatinine to an average of 106.2+/-6.4, fibrinogen and fibrin monomers to subnormal values of 3.2+/-0.2 g/l and up to 8.1+/-0.5x10-2 g/l, respectively were seen. Renal hypertrophy according to ultrasound examination was preserved with a mean kidney volume 119.7+/-3.6 cm3. Disturbances in peripheral microcirculation according to the microscopy of the bulbar conjunctiva was assessed as moderate. CONCLUSION: The development of CKD in patients with a solitary kidney is accompanied by a structural reorganization of the organ with an increase in blood pressure, an increase in its volume, a decrease in function, microcirculatory disorders and hypertensive nephropathy. Considering the prognostic significance of changes in the solitary kidney, it is important not only to control the functional parameters, but also to include reno- cardioprotective therapy as a standard, since it contributes to the preservation of the renal function and prevents the rapid progression of CKD. Thus, medical and social rehabilitation of patients with a solitary kidney is required. However, it is currently cannot be considered comprehensive.

Subcapsular hematoma in a solitary kidney: successful conservative management.

Subcapsular renal hematoma (SRH) is an infrequent complication of urologic interventions but can lead to serious consequences in patients with a solitary kidney. We present our experience with conservative management of a patient with a solitary kidney and multiple medical comorbidities who developed a SRH and subsequent renal failure after nephroureteral catheter placement. Literature on the management of this unique clinical scenario is limited. Herein, we share our experience with supportive care and temporary dialysis in a medically complex patient whose outcome is complete renal recovery.

Long-term comparative outcomes of partial nephrectomy and cryoablation in patients with solitary kidneys: a single-center analysis.

BACKGROUND: Patients with solitary kidneys are amenable to postoperative acute kidney injury (AKI) after PN. We compared the functional and oncological outcomes of cryoablation (CA) and PN in patients with a solitary kidney and a cT1a renal mass. METHODS: From a single-institution series, we analyzed 74 patients (31 PN, 43 CA) with a solitary kidney who underwent treatment for a cT1a renal mass. The functional outcomes were AKI and estimated glomerular filtration rate (eGFR) preservation. Oncological outcomes were recurrence and death. Linear mixed-effects and logistic regression models were used for functional outcomes analysis, whereas oncological outcomes were analyzed using the Kaplan-Meier method. RESULTS: Median follow-up was 63.9 months. PN group had lower median age (59 years vs. 68, P<0.001) and larger median tumor size (2.80 cm vs. 2.0, p =0.003). AKI was more common in the PN group on postoperative day 1 (58% vs. 2.8%, P<0.001). However, only one patient in the PN group required temporary dialysis in the perioperative period. eGFR preservation was similar at postoperative 3 months (89% vs. 90%, P=0.083), or 12 months (85% vs. 94%, P=0.2) follow-up. CA group had higher recurrence rate (29% vs. 3.2%, P=0.005), and worse recurrence-free survival (P=0.027). Overall survival (OS) was comparable (P=0.31). CONCLUSIONS: In a solitary kidney setting, CA is associated with a lower risk of AKI at postoperative day 1 compared to PN. Functional outcome is comparable upon longer follow-up. The local recurrence rates are significantly higher in the CA group with no significant difference in OS.

Robotic partial nephrectomy for management of renal mass in patients with a solitary kidney: can we expand the indication to T2 and T3 disease?

BACKGROUND: Management of complex renal masses is challenging in a solitary kidney setting. We retrospectively compared oncological and renal functional outcomes between robotic and open partial nephrectomy (PN) in patients with a pT2-pT3 renal mass and a solitary kidney. METHODS: From a multi-institutional series, we identified 20 robotic partial nephrectomies (RPN) and 15 open partial nephrectomies (OPN) patients confirmed to have a pT2 or pT3 renal cancer. Surgeries were performed between January 2012 and July 2019. Patients with familial renal cell carcinoma, prior ipsilateral PN, or multiple ipsilateral synchronous tumors were excluded from the analysis. Baseline characteristics, perioperative and postoperative outcomes were compared using χ2 test, Fisher's Exact Test, Mann-Whitney U Test, and Student's t-test. RESULTS: Baseline characteristics were comparable. Cold ischemia was utilized more in the open group (92.9% vs. 15.8%, P<0.001). OPN group had a longer ischemia time (48.9 min vs. 27.3 min, P<0.001), a higher major complication rate (38.5% vs. 11.1%, P=0.009), and a higher length of stay was (5 vs. 3.5 days, P=0.023). Positive surgical margin rate was comparable (20% OPN vs. 15% RPN; P=1.000). At a mean follow up of 21 months local recurrence rates (1 OPN vs. 2 RPN, P=1.000) were comparable, chronic kidney disease upstaging rate (46.7% OPN vs. 45.0% RPN, P=0.922) and estimated glomerular filtration rate preservation at one year (75.2%% in OPN vs. 79.1% RPN, P=0.707) were comparable. CONCLUSIONS: In select cases and experienced hands, the robotic approach offers a reasonable alternative to open surgery in patients with pT2 and pT3 tumors and a solitary kidney.