Management of high-grade renal injury in children

Conservative management in high-grade renal trauma: a systematic review and meta-analysis

OBJECTIVE

To systematically investigate and analyse the aggregated data from recent studies to provide a quantitative synthesis for a conservative approach to the management of high-grade kidney trauma, as accumulating evidence supports the favourable outcomes of a conservative approach.

METHODS

A comprehensive search was performed using databases, including PubMed, EBSCO, ProQuest, Google Scholar, and Cochrane Library, to identify studies relevant to high-grade renal trauma in both adult and paediatric populations. The compare review focused on comparing conservative management interventions, such as observation, rest, resuscitation, transfusion, symptomatic management, and angioembolisation, with operative management interventions. Search strategies incorporated specific medical subject headings and keywords related to conservative management, kidney trauma, mortality, and renal preservation. Random and fixed-effect meta-analyses were conducted to estimate the rates of nephrectomy and mortality, respectively.

RESULTS

A total of 36 and 29 studies were included for qualitative and quantitative synthesis, respectively. The aggregated data showed a cumulative risk difference of 0.52 (95% confidence interval [CI] 0.38-0.66, P < 0.001), indicating a higher likelihood of nephrectomy in cases where operative management was used instead of conservative management. In terms of mortality, conservative management demonstrated a lower risk difference of 0.09 (95% CI 0.05-0.13, P < 0.001).

CONCLUSION

The results indicate that opting for conservative management in cases of high-grade renal trauma, particularly for haemodynamically stable patients, presents a lower risk of mortality and reduced probability of requiring nephrectomy when compared to operative management. These findings provide strong evidence in favour of considering conservative management as a viable and effective treatment option for high-grade renal trauma.

Factors affecting and effects of hemodynamic stability of pediatric patients with grades 3-5 renal trauma: a prospective non-randomized comparative study

BACKGROUND

Researches on the effect of hemodynamic stabilization on the implantation of conservative management for pediatric high-grade renal traumas are lacking. We aimed to assess the effect of maintaining the initial hemodynamic stability of pediatric patients with grades 3-5 renal trauma on the implementation of the conservative treatment and identify its defining factors.

METHODS

A prospective study was performed on pediatric patients with grade 3-5 renal traumas who presented to our hospital during July 2020-June 2022. Hemodynamically stable patients were compared with the unstable patients for clinical characteristics, hemodynamic stabilization, and rates of success of conservative treatment.

RESULTS

Forty-three patients were studied, including 26 boys and 17 girls. Of them, 28 (65.1%) patients presented with hemodynamic stability and 15 (34.9%) patients were unstable. Overall, 32 (74.4%) patients achieved and/or maintained hemodynamic stability for conservative management. There was a significant difference in blood pressure level at presentation (p < 0.001). The improvement of the hemodynamic parameters was significant per group and, in comparison (p < 0.001). The size of hematoma was significantly smaller in patients with hemodynamic stability (p = 0.023). Despite the longer (p = 0.033) hospital stay with conservative management, the rates of blood transfusion (p = 0.597) and hospital stay (p = 0.785) were not significantly different between both groups. The rates of nephrectomy and mortality were 14% and 0%, respectively. Blood pressure was independently associated with the achievement of maintained hemodynamic stability for conservative management (p = 0.022).

CONCLUSIONS

Hemodynamic stabilization seems to be effective and safe for implementing successful conservative management for pediatric patients with high-grade renal traumas. Blood pressure was the only independent factor of maintaining hemodynamic stability.

Pediatric renal trauma: 17 years of experience at a major Scandinavian trauma center

Background

Children are at increased risk of renal injuries from blunt trauma due to their anatomic constitution. The kidney is injured in 5-20% of pediatric patients with blunt abdominal trauma. During the last decades, the management of pediatric renal injuries has evolved toward non-operative management (NOM) unless the patient is hemodynamically compromised. The aim of the present study was to assess contemporary treatment strategies and evaluate outcomes in pediatric patients with renal injuries admitted to a major Scandinavian trauma center.

Methods

A retrospective cohort study of all trauma patients under 18 years admitted to our institution from January 1, 2003 to December 31, 2019 with main focus on patients with renal injury. Outcomes for two time periods were compared, 2003-2009 (Period 1; P1) and 2010-2019 (Period 2; P2), and the study cohort was also stratified into age groups, survivors and non-survivors and severity of renal injury.

Results

In total, there were 4230 pediatric patients included in Oslo University Hospital Trauma Registry during this 17-year period and of these 115 (2.7%) had a renal injury. Nephrectomy was performed in four (3.5%) of the patients, angiographic embolization five (4.3%) and ureteral stent placement was performed in six patients (5.2%) due to urinary extravasation. Seven patients died, implying a crude mortality of 6.1%, with one exception secondary to traffic-related incidents. None of the deaths were attributed to renal injury and mortality fell to 1.2% in P2.

Discussion

This study on contemporary pediatric renal trauma care is one of the largest from a single institution outside the USA. Our results clearly show that NOM, including minimally invasive procedures in selected cases, is achievable in more than 90% of cases with low mortality and morbidity.

Level of evidence

Level IV.

Routine repeat imaging may be avoidable for asymptomatic pediatric patients with renal trauma

INTRODUCTION

AUA Urotrauma guidelines for renal injury recommend initial nonoperative management followed by repeat CT imaging for stable patients with deep lacerations or clinical signs of complications. Particularly in pediatric patients where caution is taken to limit radiation exposure, it is not known whether routine repeat imaging affects clinical outcomes.

OBJECTIVE

Our objective was to determine whether routine repeat imaging is associated with urologic intervention or complications in nonoperatively managed pediatric renal trauma.

METHODS

We retrospectively analyzed 337 pediatric patients with blunt and penetrating renal trauma from a prospectively collected database from 2005 to 2019 at a Level I trauma center. Exclusion criteria included age >18 years old, death during admission (N = 39), immediate operative intervention (N = 28), and low-grade renal injury (AAST grades I-II, N = 91). Routine repeat imaging was defined as reimaging in asymptomatic patients within 72 h of initial injury. Patients were placed into three imaging groups consisting of: (A) those with routine repeat imaging, (B) those reimaged for symptoms, or (C) those not reimaged. Comparisons were made using logistic regression controlling for grade of renal injury.

RESULTS

Of the included 179 children, 44 (25%) underwent routine repeat imaging, 20 (11%) were reimaged for symptoms, and 115 patients (64%) were managed without reimaging. Compared to patients who were reimaged for symptoms, asymptomatic patients in the routine repeat imaging group and without reimaging group were significantly less likely to develop a complication (16% and 7% vs. 55%, p < 0.001) or require delayed urologic procedure (5% and 1% vs. 25%, p = 0.007). Comparing the routine repeat imaging group to those without reimaging, we found no difference in complications (p = 0.47), readmissions (p = 0.75), or urologic interventions (p = 0.50).

CONCLUSION

Despite suffering high-grade (III-IV) renal injuries, the majority of pediatric patients who remained asymptomatic during the first three days of hospitalization did not require a urologic intervention. Foregoing repeat imaging was not associated with a higher rate of complications or delayed procedures, supporting that routine repeat imaging may expose these children to unnecessary radiation and may be avoidable in the absence of signs or symptoms of concern.

Characteristics and outcomes of pediatric blunt renal trauma: a nationwide cohort study in Japan

PURPOSE

The aim of this study was to describe epidemiologic features of pediatric blunt renal trauma.

METHODS

We performed a retrospective analysis using the Japan Trauma Data Bank over 15 years. We included patients younger than 18 years with blunt renal trauma. We analyzed temporal trends and variations across age groups in patient characteristics, intervention, and in-hospital mortality. We also assessed factors associated with in-hospital mortality.

RESULTS

We identified 435 pediatric patients with blunt renal trauma. Their median age was 14 years and median Injury Severity Score (ISS) was 17. The most common mechanism of injury was traffic accident in all age groups. Nephrectomy was performed in 3.2%, and the overall in-hospital mortality was 4.6%, both of which showed decreasing trends. The most common mechanism of injury by age group was a pedestrian accident in infants/toddlers/preschoolers (43.5%), pedestrian accident in middle childhood (18.5%), bicycle accident in young teens (24.7%), and motorcycle accident in teenagers (41.2%). Sports-related injury was common in young teens (23.3%) and teenagers (15.2%). Factors such as ISS, shock, concomitant injury, and nephrectomy were associated with high in-hospital mortality.

CONCLUSIONS

We described decreasing trends in nephrectomy and in-hospital mortality in pediatric blunt renal trauma and found traffic accident and sports-related injury were common in the pediatric population in Japan.

Trauma in pediatric urology

In pediatric trauma, the kidney is the most commonly injured organ of the urinary tract. Renal trauma occurs in 10% to 20% of all pediatric blunt abdominal trauma cases. The vast majority of renal injuries can be treated conservatively. However, cases associated with hemodynamic instability require operative interventions. Injuries to the ureter, bladder or urethra are almost exclusively encountered in polytraumatized children. The aim of this article is to give an overview on traumatic injuries to the pediatric urinary system.

Successful management of gunshot wound to the chest resulting in multiple intra-abdominal and thoracic injuries in a pediatric trauma patient: A case report and literature review

INTRODUCTION

Trauma remains the leading cause of mortality in the pediatric population. Penetrating thoracic injuries can result in devastating trauma to multiple organ systems. When these injuries occur, prompt diagnosis and swift treatment of internal organ injury are of utmost importance.

CASE PRESENTATION

A 13-year-old male presented to our Trauma Center after sustaining a gunshot wound (GSW) to the left chest. Despite his hemodynamic stability on presentation, CT scan revealed multiple injuries including splenic and renal lacerations. Exploratory laparotomy resulted in splenectomy, but no intervention was performed for the renal laceration. Instead, clinical monitoring alone was sought. Patient was discharged on hospital day 13 in stable condition.

DISCUSSION

Pediatric penetrating injuries secondary to GSWs can impact multiple organ systems. Despite hemodynamic stability on presentation, adequate staging of internal damage with CT allowed a targeted approach. In our case, non-operative management of the renal injury was implemented after hemorrhage control of his additional injuries. Failure to have done so would have inevitably complicated his overall management and made kidney salvage not feasible.

CONCLUSION

Prompt diagnosis and treatment are required in order to prevent significant morbidity and mortality in the pediatric patient from GSW-mediated penetrating thoracic injuries. Despite hemodynamic stability on presentation, patients should be emergently assessed for severe injury, with immediate surgical management as needed. Failure to do so could lead to rapid clinical deterioration, and inability to enact other conservative measures that lead to positive outcomes.

Impact of trauma center designation in pediatric renal trauma: National Trauma Data Bank analysis

INTRODUCTION

The pediatric kidney is the most common urinary tract organ injured in blunt abdominal trauma. Trauma care in the United States has been established into a hierarchical system verified by the American College of Surgeons (ACS). Literature evaluating management of pediatric renal trauma across trauma tier designations is scarce.

OBJECTIVE

To examine the differences in the management and outcomes of renal trauma in the pediatric population based on trauma level designation across the United States.

STUDY DESIGN

We performed a review of the ACS - National Trauma Data Bank database. Pediatric patients (age 0-18 years) who were treated for renal injury between years 2011-2016 were identified. Our primary outcome was the difference in any complication rate amongst Level I versus Non-Level I trauma centers. Management strategies were evaluated as secondary outcomes. Propensity score matching (PSM) was utilized to adjust for baseline differences between cohorts. Multivariable regression analysis was performed to determine the independent effects of individual factors on complications, operative intervention, minimally invasive procedure, and blood transfusions.

RESULTS

Overall, 12,097 pediatric patients were diagnosed with renal trauma between 2011 and 2016 using target ICD-9 and AAST codes. After PSM, there was a total of 1623 subjects withing each group. No difference was identified between groups for occurrence on any complication [105 (6.5%) vs 114 (7.0%), p = 0.576. There were no differences in the rate of minimally invasive interventions [67 (4.1%) vs 48 (3.0%), p = 0.087], operative intervention [58 (3.6%) vs 68 (4.2%), p = 0.413], or nephrectomy [42 (2.6%) vs 47 (2.9%), p = 0.667] between Level I and Non-Level I trauma designations, respectively. Length of stay was longer in the Level I cohort compared to Non-Level I (days (SD)) [6.9 (8.8) vs 6.2 (7.9), p = 0.024. When specifically looking at risk factors associated with operative intervention, higher renal injury grade and injury severity score were highly correlated, whereas, trauma level designation was not found to be predictive for more aggressive management.

DISCUSSION & CONCLUSION

Our results corroborate with previous literature that renal injury grade and injury severity score are strong predictors of morbidity, invasive management, and complications. Pediatric renal trauma was managed similarly across trauma center designations, with the rate of complication and intervention more prevalent in patients with high grade renal injuries and concomitant injuries. Further studies are necessary to identify patients who will benefit most from transfer to a level I center.

"Functional outcome in pediatric grade IV renal injuries following blunt abdominal trauma salvaged with minimally invasive interventions"

BACKGROUND

Non-operative management of higher-grade renal injuries has gradually become accepted in pediatric circles following multiple studies over the past decade which showed good renal salvage rates. However, some children do fail this conservative approach and need interventions which are mostly minimally invasive. There is still paucity of studies on the functional outcomes in this unique subgroup of patients. In this study, we review our management and functional outcome of children with grade IV renal injury due to blunt trauma of abdomen managed with minimally invasive interventions (MII) in a tertiary referral center.

AIM

The present study seeks to summarize contemporary management of pediatric grade IV renal injury due to blunt trauma at our tertiary care center and to assess the functional outcomes in the subgroup who needed MII.

MATERIALS AND METHODS

A retrospective review was performed on children≤18 years with abdominal blunt trauma managed at our tertiary care facility over the past 10 years (January 2008-January 2018) to identify those with grade IV renal injuries. Data collected included demographic data like age, sex, mechanism of injury, incidence of hematuria, incidence of pre-existing urologic conditions, associated non-renal injuries, transfusion requirements, imaging findings, type of interventions, length of hospital stay, complications and outcomes on follow up.

RESULTS

Review of our institutional database identified 10 children with grade IV renal injury. Mean age was 11.7 ± 3.6 years (range, 6-18) and majority (6/10) were male. Motor vehicle collision and fall from heights were the commonest mechanisms of injury. While one patient responded to non-operative management, one girl needed emergency renal exploration and later nephrectomy. Eight needed minimally invasive interventions following initial non-operative management. One patient needed nephrectomy due to delayed hemorrhage while three patients needed delayed open reconstruction. The salvage rate in the group which needed interventions was 87.5% (7 of 8) however, the functional outcome was good only in 50% (4 of 8) of patients. The outcomes were better in those who were managed with MII earlier (3/4) compared to those who underwent delayed intervention (1/4). The median hospital stay was 11.5 days (range 7-34 days).

CONCLUSION

Pediatric patients with non-exsanguinating grade IV renal injuries due to blunt trauma who fail non-operative management and need minimal invasive interventions have good renal salvage rates however, the functional outcomes are poorer. Judicious and early use of these minimally invasive interventions, instead of persisting with non-operative management can possibly improve these functional outcomes.

Kidney and uro-trauma: WSES-AAST guidelines

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

Nationwide Procedural Trends for Renal Trauma Management

OBJECTIVE

To characterize national trends in procedural management of renal trauma.

BACKGROUND

Management of renal trauma has evolved to favor a more conservative approach. For patients requiring intervention, there is a paucity of information to characterize the nature of procedural therapy administered.

METHODS

A retrospective cross-sectional analysis was performed using data contained within the National Trauma Data Bank. The National Trauma Data Bank is a voluntary data repository managed by the American College of Surgeons, containing data regarding trauma admissions at 747 level I to V trauma centers throughout the United States and Canada. Participants included any patient with renal trauma requiring intervention from 2002 to 2012. They were identified according to International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, with codes 866.00 through 866.03 for blunt renal trauma, and codes 866.10 through 866.13 for penetrating trauma. Cases were separated into those requiring nephrectomy, renorrhaphy, or endovascular repair based on ICD-9 procedure code. The number of cases performed each year and yearly trends as measured by linear regression.

RESULTS

A total of 4296 cases were reported during the study period. Of these cases, 2635 involved blunt trauma and 1661 involved penetrating injury. There was a significant increase in the percentage of cases managed by endovascular means for both blunt and penetrating trauma (R = 0.92, P < 0.01; and R = 0.86, P < 0.01, respectively). This was primarily at the expense of nephrectomy, with cases showing significant decline in both groups.

CONCLUSIONS

National trends for procedural management of renal trauma are toward less invasive interventions. These trends suggest favorable change towards renal preservation and decreased morbidity, potentially facilitated, in part, by improved radiographic staging and endovascular techniques, and also increased provider awareness of the safety and value of conservative management.

Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society

BACKGROUND

Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma.

METHODS

Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded.

RESULTS

When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%.

CONCLUSION

Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma.

LEVEL OF EVIDENCE

Guidelines study, level III.

Nonoperative Management of Blunt Solid Organ Injury in Pediatric Surgery

In the last decade, higher rates of nonoperative management of liver, spleen, and kidney injuries have been achieved. An algorithmic approach may improve success on a national level. Factors for success include management strategy based on physiologic status of the child, early attempt at resuscitation using blood products, and appropriate use of adjuncts. Shorter hospitalizations are appropriate for children who have not bled significantly, and discharge instructions facilitate the safety of early discharge. Although routine imaging is not required for liver or spleen injury, symptoms should prompt reevaluation. Reimaging of renal injuries remains in common use.