Long-term renal outcomes in patients with traumatic renal injury after nephrectomy: A nationwide cohort study

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.

Traumatic injuries to the renal blood vessels and in-hospital renal complications in patients with penetrating or blunt trauma

Background

Traumatic injuries to renal blood vessels (IRBV) can have significant consequences for patients, impacting their mortality, morbidity, and quality of life.

Objective

This study aimed to compare trauma types and injury characteristics, vital signs, and outcomes in patients with and without IRBV (nIRBV) and examine whether IRBV and pre-existing renal dysfunction affected the likelihood of in-hospital renal complications (iHRC).

Materials and Methods

After identifying penetrating and blunt trauma victims with IRBV in the National Trauma Data Bank, patient demographics, injury-related variables, treatment outcomes, and deaths under care were analyzed and compared.

Results

Of the 994,184 trauma victims, 610 (0.6%) experienced IRBV. Victims in the IRBV group (IRBVG) had a significantly higher frequency of penetrating injuries (19.5% vs. 9.2%, P < 0.001) and higher injury severity score (ISS ≥25, 61.5% vs. 6.7%). Most injuries in both groups were unintentional, although a higher frequency of assault was noted in the IRBVG. The incidence of iHRC was higher in the IRBVG (6.6%) than in the nIRBVG (0.4%; P < 0.001). The IRBV {OR = 3.5 [95% CI = (2.4-5.0)]}, preexisting renal disorders {OR = 2.5 [95% CI = (2.1-2.9)]}, and in-hospital cardiac arrest {OR = 8.6 [95% CI = (7.7-9.5)]} were found to be among the factors associated with a higher risk of iHRC.

Conclusions

IRBV and pre-existing renal disorders considerably increased the risk of developing iHRC. Due to the long- and short-term consequences of associated cardiovascular, renal, and hemodynamic complications, victims of IRBV require specialized renal management and close monitoring.

Surgical and oncological outcomes of distal gastrectomy compared to total gastrectomy for middle‑third gastric cancer: A systematic review and meta‑analysis

Distal gastrectomy (DG) and total gastrectomy (TG) are the most common types of radical surgery for patients with middle-third gastric cancer (MTGC). However, the indications and benefits of the two procedures still remain controversial. The present meta-analysis aimed to compare the surgical and oncological outcomes of DG and TG in the treatment of MTGC. A rigorous literature review was performed in the databases of PubMed, Embase, Web of Science, China National Knowledge Infrastructure and Chinese BioMedical Literature to retrieve studies published up to February 2022. The Newcastle-Ottawa Scale was used to assess the quality of included studies and a meta-analysis was performed using RevMan 5.3 software. A total of 12 retrospective studies performing comparisons of DG and TG were included in the present meta-analysis. For patients who underwent DG, a lower rate of overall post-operative complications, anastomosis leakage and intro-abdominal infection was determined. No significant difference was observed between DG and TG in the 5-year overall survival when the proximal resection margin ranged from 3 to 5 cm. Although DG was associated with a higher 5-year overall survival rate when compared to TG, there was no significant difference in the stratified analyses by TNM stage. In conclusion, the prognosis of MTGC did not depend on the extent of gastrectomy. With lower complications and acceptable oncological outcomes, DG was a safe and feasible surgical procedure for MTGC when a negative proximal margin was confirmed.

The effect of transarterial embolization versus nephrectomy on acute kidney injury in blunt renal trauma patients

PURPOSE

The impact of transarterial embolization (TAE) and nephrectomy on acute kidney injury (AKI) in blunt renal trauma patients remains unclear, and we used the National Trauma Data Bank (NTDB) to investigate this issue.

METHODS

Adult patients from the NTDB between 2007 and 2015 who survived traumatic events with blunt injuries were eligible for inclusion. The exclusion criteria were those without outcome information, who required dialysis, or with chronic renal failure prior to the traumatic injury. Patients sustaining hepatic, splenic, or pelvic fractures or who had bilateral nephrectomy were also excluded. The patients were divided into three treatment groups, including conservative treatment, TAE, and nephrectomy. Two statistical models, logistic regression (LR) and inverse probability treatment weighting (IPTW), were used to clarify the AKI predictors.

RESULTS

The study included 10,096 patients. There were 9697 (96.0%), 202 (2.0%) and 197 (2.0%) patients in the conservative, TAE and nephrectomy groups, respectively. Nephrectomy was a statistically significant predictor of AKI in blunt renal trauma patients in the standard LR (odds ratio [OR], 4.58; 95% confidence interval [CI] 1.92-10.38; p < 0.001) and IPTW (OR, 5.16; 95% CI 1.07-24.85; p = 0.023) models. In addition, TAE was not a risk factor for AKI in blunt renal trauma patients (p > 0.05 in all models).

CONCLUSION

AKI is less likely affect patients with blunt renal trauma with TAE than those with nephrectomy. Nephrectomy is a risk factor for AKI in blunt renal trauma patients. TAE should be considered first when blunt renal trauma patients need a hemostatic procedure.

Nephrectomy After High-Grade Renal Trauma is Associated With Higher Mortality: Results From the Multi-Institutional Genitourinary Trauma Study (MiGUTS)

OBJECTIVE

To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates.

METHODS

We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS).

RESULTS

A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55).

CONCLUSION

Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

Protection against acute renal injury by naturally occurring medicines which act through Nrf2 signaling pathway

The cellular defense pathway plays a key role in maintaining the homeostasis, tissues and organisms. Nuclear factor E2-related factor 2 (Nrf2), as a key cell signaling pathway, plays an important role in encoding detoxification enzymes and other stress response mediators. Recent studies have shown that it is closely related to the prevention and treatment of acute kidney injury (AKI). Therefore, this article reviews the protective effects of Nrf2-related signaling pathways on acute kidney injury, and summarizes the strategies of natural pharmaceutical ingredients such as flavonoids, alkaloids, terpenes, phenylpropionic acid, polyphenols, and polysaccharides to prevent and treat acute kidney injury. It is of great significance to further study the relationship between Nrf2 regulated signal pathway and kidney disease and the development of new medicines for acute kidney injury treatment. It can also provide new ideas and treatment strategies for clinical treatment of acute kidney injury. PRACTICAL APPLICATIONS: This article reviewed the mechanisms by which the active ingredients of natural medicines slow down acute kidney injury through the Nrf2 pathway. It will help us to understand the regulatory role of the Nrf2 pathway in AKI more comprehensively, and provide a theoretical basis for further exploring the mechanism of more natural drugs to reduce acute kidney injury.