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Renal Trauma George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas 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 I II III Injury Contusion • microscopic or gross hematuria • urologic studies normal Hematoma • subcapsular, nonexpanding • no parenchymal laceration Hematoma • nonexpanding perirenal hematoma confined to renal retroperitoneum Laceration • < 1.0-cm parenchymal depth of renal cortex • no urinary extravasation Laceration • > 1.0-cm parenchymal depth of renal cortex • no collecting system rupture or extravasation Laceration • parenchymal laceration extending through renal cortex, medulla, and collecting system Vascular • main renal artery or vein injury with contained hemorrhage Laceration • completely shattered kidney Vascular • avulsion of renal hilum that devascularizes kidney IV V Description of Injury 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, 2010 Children’s Mercy 1995 - 2007 • All patients with blunt renal trauma • Mean age 11 yrs • MVC 44% • Falls 30% • Sports 22% • Grade I Grade II Grade III Grade IV Grade V - 26% 23% 35% 13% 3% J 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, 2010 Renal Trauma • CMH is currently participating in multiinstitutional, 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