Specifically, we assessed how patient comorbidities—including hypertension, obesity, smoking, and older age—interact with WIT to influence the risk of AKI after PN. Patients were stratified into low-, intermediate-, and high-risk groups using a weighted comorbidity scoring system that accounted for each comorbidity’s relative contribution to AKI risk. This approach allowed us to comprehensively analyze how WIT affects renal function across varying levels of comorbidity burden, providing a detailed understanding of its disproportionate impact on patients with higher risk profiles.
Our findings revealed that patients with a high comorbidity burden (three or more comorbidities) were three times more likely to develop AKI compared to low-risk patients. The incidence of AKI was 12%, 19%, and 29% in the low-, intermediate-, and high-risk groups, respectively. Notably, WIT had a more pronounced effect on intermediate- and high-risk patients, with a per-minute increase in AKI risk of 6% and 8%, respectively. By the 25-minute mark, the probability of AKI reached 35% in high-risk patients. In contrast, no significant relationship between WIT and AKI was observed in low-risk patients. Furthermore, patients who developed postoperative AKI faced a substantially higher 10-year risk of CKD progression to stage ≥IIIB (36%) compared to those without AKI (12%).
These findings underscore the critical importance of tailored surgical planning and preoperative risk assessment for patients with significant comorbidities. Minimizing WIT during PN is particularly essential for high-risk patients to mitigate AKI and its long-term consequences. Multidisciplinary preoperative counseling, involving nephrologists and nutritionists, can further optimize patient outcomes by addressing the multifaceted challenges posed by complex comorbidity profiles.
Our study also contributes to the ongoing debate surrounding the use of warm ischemia versus no-ischemia techniques during PN by emphasizing the critical role of patient characteristics. Specifically, by demonstrating that ischemia time disproportionately impacts patients with a higher comorbidity burden, we support the hypothesis that the use of intraoperative ischemia should consider not only tumor complexity and oncological priorities but also individual patient profiles, particularly for those most vulnerable to ischemia-related complications.
Despite the robustness of our prospectively maintained database, the single-center design may limit the generalizability of our findings. Moreover, the lack of data on long-term management of comorbidities and nephroprotection protocols represents a limitation. Future research should address these gaps using multicenter, prospective frameworks to build on our findings.
By integrating patient-specific risk factors with surgical variables, this study lays the groundwork for a more personalized approach to nephron-sparing surgery, ensuring optimal preservation of renal function while maintaining oncological control, and aiding optimal patient selection.
Written by: Pietro Scilipoti, MD & Giuseppe Rosiello, MD
- Department of Urology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Urological Research Institute (URI), Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy