Renal Trauma

George W. Holcomb, III, M.D., MBASurgeon-in-Chief

Children’s Mercy HospitalKansas City, MO

Renal Trauma• Trauma is most common cause of death in children

• Injuries to the kidneys account for 60% of

genitourinary injuries• 90% blunt trauma

• Usually do not require operation

• 10-20% penetrating trauma

• More often require operation

• Deceleration/flexion injuries

• Produce renal arterial or venous injuries

Renal Trauma• Due to their size and location, kidneys are susceptible

to injury from blunt trauma

• Children are more susceptible than adults to major renal injury• Less perirenal fat

• Weaker abdominal musculature

• Less well-ossified thoracic cage

• Kidneys with congenital abnormalities are at increased risk of injury

• Pediatric evaluation and treatment guidelines not clearly defined for children

Renal Trauma

• Standard Imaging Modality – (U.S.)

• CT scan often performed in trauma w/u

• CT scan recommended in patients with hematuria

• Ultrasound may be used to screen hemodynamically unstable patients

• FAST 95% specificity, but 33-89% sensitivity

Renal Trauma• Management goal: renal salvage

• Indications for immediate exploration• Hemodynamic instability• Penetrating injury – unstable patient• Associated non-renal injuries

• Nephrectomy required in less than 10% of cases

• Isolated penetrating renal injury in stable patient can be managed conservatively

• Aggressive radiologic, laboratory and clinical efforts

important in managing patients w/o operation

American Association for the Surgery of Trauma Injury Scale

Grade Injury Description of Injury

I

Contusion • microscopic or gross hematuria• urologic studies normal

Hematoma • subcapsular, nonexpanding• no parenchymal laceration

II

Hematoma •nonexpanding perirenal hematoma confined to renal retroperitoneum

Laceration • < 1.0-cm parenchymal depth of renal cortex • no urinary extravasation

IIILaceration • > 1.0-cm parenchymal depth of renal cortex

• no collecting system rupture or extravasation

IV

Laceration •parenchymal laceration extending through renal cortex, medulla, and collecting system

Vascular • main renal artery or vein injury with contained hemorrhage

VLaceration • completely shattered kidney

Vascular • avulsion of renal hilum that devascularizes kidney

Renal Trauma

• Stable grade I-III injuries• Managed non-operatively

• Severe grade IV-V• Require careful selection based on

• hemodynamic stability

• mechanism

• associated non-renal injuries

• Stable patients may need monitoring in ICU setting

Renal Trauma

• Management• Inconclusive data

• Antibiotics• Likely only needed when stent placed

• Bedrest• Variable practice: bedrest for 5-7 days, or until

hematuria clears, or once physically able

• No consensus

Renal Trauma

• Management

• Ureteral stent indications

• 80% of grade IV and V collecting system injuries heal without intervention

• If collecting system extravasation does not resolve within two weeks, stenting is then considered

• Symptomatic urinomas may require stenting

• Lack of contrast in ipsilateral ureter may indicate significant injury, necessitating stent

Renal Trauma

• Complications• Hypertension• Estimated incidence: 0 - 7.5%

• Follow-up imaging• Little data to support its use

J Pediatr Surg 45:1311-1314, 2010J Pediatr Surg 45:1311-1314, 2010

Children’s Mercy1995 - 2007

• All patients with blunt renal trauma

• Mean age 11 yrs

• MVC - 44%

• Falls - 30%

• Sports - 22%

• Grade I - 26%

Grade II - 23%

Grade III - 35%

Grade IV - 13%

Grade V - 3%J Pediatr Surg 45:1311-1314, 2010J Pediatr Surg 45:1311-1314, 2010

Children’s Mercy• Isolated renal injury - (44%)

• Bed rest - 3.8 ± 1.9 d (mean)• Hospital - 3.8 ± 3.1 d (mean)

• Blood tx – 15 pts• Mean vol – 700 c• Op – 6 pts – None for renal injury• No tx in isolated renal injury• No tx Grade IV or V injury

• Renal salvage – 99.1%• One nephrectomy in pt w/ESRD

• HTN – 3 pts – 1 resolved

• Urinoma – 1 pt – resolved w/drainage

J Pediatr Surg 45:1311-1314, 2010J Pediatr Surg 45:1311-1314, 2010

Renal Trauma• CMH is currently participating in multi-

institutional, prospective, randomized trial with long-term follow-up

• Patients allowed out of bed when physically able

• Daily UA while in hospital

• Once discharged, weekly UA until hematuria is cleared

• Discharged when patients meet general discharge criteria

• 3 year follow-up for hypertension

References 1. Fraser, JD, Aguayo P, Ostlie DJ, et al: Review of the evidence on the

management of blunt renal trauma in pediatric patients. Pediatr Surg

Int (2009) 25:125-132.

2. Holcomb GW III, Murphy JP. Ashcraft’s Pediatric Surgery. 5th ed.

Philadelphia, PA: Saunders An Imprint of Elsevier, 2010.

3. Nerli RB, Metgud T, Patil S, et al: Severe renal injuries in children

following blunt abdominal trauma: selective management and outcome.

Pediatr Surg Int (2011) 27:1213-1216

4. Suson KD, Gupta AD, Wang MH. Bloody urine after minor trauma in

a child: isolated renal injury versus congenital anomaly? J Pediatr.

(2011) 159:870.

QUESTIONS

www.cmhclinicaltrials.com