Renal trauma in the west of Ireland--a regional review

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.

Profile of renal artery embolization (RAE) for renal trauma: A comparison of data from two major trauma center

OBJECTIVE

To evaluate usage of renal artery embolization (RAE) for renal injuries and discuss the indications for this treatment.

MATERIALS AND METHODS

A retrospective study was performed evaluating the electronic medical records of all patients with renal trauma admitted to two major comprehensive hospitals in Shantou city from January 2006 to December 2015.

RESULTS

There were 264 and 304 renal traumatic patients admitted to hospital A and B, respectively. LGRT was the reason for presentation in the majority of patients (522, 91.9%). A total of 534 (94.0%) patients were treated conservatively. RAE was performed in 9 patients from 2012 to 2015 at hospital A, including in 6 patients (6/9, 66.7%) with LGRT, and 3 patients (3/9, 33.3%) with HGRT. No patient underwent interventional therapy (RAE) at hospital B during the same period. No significant differences in the operative rate of hospital A were observed between the two time periods (2006-2011 and 2012-2015). The operative rate for LGRT between the two hospitals from 2006 to 2011 and 2012 to 2015 was not significantly different. Hospital A showed a significant decrease in the rate of conservative treatment for patients with LGRT. In the univariate and multivariate analyses, the AAST renal grade both were significantly associated with undergoing RAE.

CONCLUSIONS

LGRT was present in the majority of patients, and most cases of renal trauma could be treated with conservative treatment. RAE was well utilized for the treatment of renal trauma. However, some patients with LGRT were treated with unnecessary interventional therapy.

Renal trauma: a 6-year retrospective review from a level 1 trauma center in Denmark

Background: Management of renal trauma injuries is shifting towards more conservative approaches in hemodynamically stable adult patients, even for high grade and/or penetrating trauma. The objective of this study was to analyze the patterns of injury, management and complications in renal trauma patients at a Danish university hospital with a level 1 trauma center.Method: Patients diagnosed with renal trauma at Rigshospitalet, Copenhagen, Denmark, between January 2010 and December 2015 were identified retrospectively by the ICD-10 code. Data were collected from electronic patient records. Imaging was classified by radiologists.Results: Out of 107 patients identified, blunt injuries comprised 93%. Median age was 28. The distribution of injury grade according to AAST was 20% grade I, 4% grade II, 33% grade III, 33% grade IV and 10% grade V. All patients with grade I-III were managed conservatively. Two patients were treated with angioembolization (1 with grade IV and 1 with grade V). Five patients with grade IV were treated with an internal ureteral stent and one patient with grade IV blunt trauma had an emergency nephrectomy performed. Overall complication rate was 7%. No patient died due to their renal injury. Renal function was normal in all patients at discharge, assessed by eGFR measurement. Of the 50% of patients who were followed up with a renography, none developed obstruction due to the renal trauma.Conclusion: The vast majority of renal injuries were due to blunt trauma. Hemodynamically stable patients, even with penetrating and/or high-grade blunt trauma, were managed non-operatively and there was a low rate of complications.

Operative and nonoperative management for renal trauma: comparison of outcomes. A systematic review and meta-analysis

Introduction

Preservation of kidney and renal function is the goal of nonoperative management (NOM) of renal trauma (RT). The advantages of NOM for minor blunt RT have already been clearly described, but its value for major blunt and penetrating RT is still under debate. We present a systematic review and meta-analysis on NOM for RT, which was compared with the operative management (OM) with respect to mortality, morbidity, and length of hospital stay (LOS).

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed for this study. A systematic search was performed on Embase, Medline, Cochrane, and PubMed for studies published up to December 2015, without language restrictions, which compared NOM versus OM for renal injuries.

Results

Twenty nonrandomized retrospective cohort studies comprising 13,824 patients with blunt (2,998) or penetrating (10,826) RT were identified. When all RT were considered (American Association for the Surgery of Trauma grades 1–5), NOM was associated with lower mortality and morbidity rates compared to OM (8.3% vs 17.1%, odds ratio [OR] 0.471; 95% confidence interval [CI] 0.404–0.548; P<0.001 and 2% vs 53.3%, OR 0.0484; 95% CI 0.0279–0.0839, P<0.001). Likewise, NOM represented the gold standard treatment resulting in a lower mortality rate compared to OM even when only high-grade RT was considered (9.1% vs 17.9%, OR 0.332; 95% CI 0.155–0.708; P=0.004), be they blunt (4.1% vs 8.1%, OR 0.275; 95% CI 0.0957–0.788; P=0.016) or penetrating (9.1% vs 18.1%, OR 0.468; 95% CI 0.398–0.0552; P<0.001).

Conclusion

Our meta-analysis demonstrated that NOM for RT is the treatment of choice not only for AAST grades 1 and 2, but also for higher grade blunt and penetrating RT.

"Management of blunt renal injury: what is new?"

The diagnosis, workup and management of blunt renal injury have evolved greatly over the past decades. Evaluation and management of blunt renal injury echoes the increasing success of nonoperative management in other blunt abdominal solid organ injury, such as liver and spleen. Decision-making difficulties still remain regarding the optimal imaging, grading and degree of interventional or operative exploration used. Increasingly, initial nonoperative management has gained acceptance and appears to be applicable even high-grade injuries. Emerging techniques in highly sensitive imaging as well as interventional angiography have allowed safe nonoperative management in the appropriate patient. This review will focus on the contemporary workup and management of blunt renal injury while focusing on some of the emerging literatures in regard to refined imaging and grading of injuries as well as techniques to increase the success of nonoperative management.