Renal Injury: 5-Year Experience and Literature Review

International Alliance of Urolithiasis (IAU) consensus on miniaturized percutaneous nephrolithotomy

Over the past three decades, there has been increasing interest in miniaturized percutaneous nephrolithotomy (mPCNL) techniques featuring smaller tracts as they offer potential solutions to mitigate complications associated with standard PCNL (sPCNL). However, despite this growing acceptance and recognition of its benefits, unresolved controversies and acknowledged limitations continue to impede widespread adoption due to a lack of consensus on optimal perioperative management strategies and procedural tips and tricks. In response to these challenges, an international panel comprising experts from the International Alliance of Urolithiasis (IAU) took on the task of compiling an expert consensus document on mPCNL procedures aimed at providing urologists with a comprehensive clinical framework for practice. This endeavor involved conducting a systematic literature review to identify research gaps (RGs), which formed the foundation for developing a structured questionnaire survey. Subsequently, a two-round modified Delphi survey was implemented, culminating in a group meeting to generate final evidence-based comments. All 64 experts completed the second-round survey, resulting in a response rate of 100.0%. Fifty-eight key questions were raised focusing on mPCNLs within 4 main domains, including general information (13 questions), preoperative work-up (13 questions), procedural tips and tricks (19 questions), and postoperative evaluation and follow-up (13 questions). Additionally, 9 questions evaluated the experts' experience with PCNLs. Consensus was reached on 30 questions after the second-round survey, while professional statements for the remaining 28 key questions were provided after discussion in an online panel meeting. mPCNL, characterized by a tract smaller than 18 Fr and an innovative lithotripsy technique, has firmly established itself as a viable and effective approach for managing upper urinary tract stones in both adults and pediatrics. It offers several advantages over sPCNL including reduced bleeding, fewer requirements for nephrostomy tubes, decreased pain, and shorter hospital stays. The series of detailed techniques presented here serve as a comprehensive guide for urologists, aiming to improve their procedural understanding and optimize patient outcomes.

Study on the mechanism of Shenkang injection in the treatment of chronic renal failure based on the strategy of "Network pharmacology-Molecular docking-Key target validation"

OBJECTIVE

To explore the potential mechanism of Shenkang injection (SKI) in the treatment of chronic renal failure based on network pharmacology and molecular docking technology, and to verify the core targets and key pathways by using the renal failure model.

METHODS

The active components and targets of Shenkang injection were retrieved by TCMSP database, and the disease related targets were obtained by OMIM, GeneCards and other databases. Then, the intersection was obtained, and were imported into String database for PPI analysis. After further screening of core targets, GO and KEGG analysis were performed. Autodock software was used to predict the molecular docking and binding ability of the selected active ingredients and core targets. Chronic renal failure (CRF) model was established by adenine induction in rats, and the pathological observation of renal tissues was conducted. Meanwhile, the effects of Shenkang injection and its active components on core targets and pathways of renal tissues were verified.

RESULTS

The results of network pharmacology showed that the main components of Shenkang injection might be hydroxysafflor yellow A (HSYA)、tanshinol、rheum emodin、Astragaloside IV. Through enrichment analysis of core targets, it was found that Shenkang injection may play an anti-chronic renal failure effect through PI3K-Akt signaling pathway. Molecular docking results showed that the above pharmacodynamic components had strong binding ability with the target proteins PI3K and Akt. The results of animal experiments showed that renal function indexes of Shenkang injection group and pharmacodynamic component group were significantly improved compared with model group. HE staining results showed that the pathological status of the kidney was significantly improved in SKI and pharmacodynamic component treatment groups. Immunohistochemical results showed that the renal fibrosis status was significantly reduced in SKI and pharmacodynamic component treatment groups. q-RTPCR and WB results showed that the expression levels of PI3K and Akt were significantly decreased in the treatment groups (P< 0.05).

CONCLUSIONS

Shenkang injection may inhibit PI3K-Akt signaling pathway to play an anti-chronic renal failure role through the pharmacodynamic component hydroxysafflor yellow A (HSYA), tanshinol, rheum emodin, Astragaloside IV.

Surgical tactics in fire kidney injury and the first experience in performing laparoscopic nephrectomy at the II level of medical support (role II) in combat conditions: Case report

INTRODUCTION AND IMPORTANCE

According to the data from the American Urological Association (AUA) and the European Urological Association (EAU) (2020), kidney is the most frequently damaged organ of the genitourinary system. Kidney damage occurs in approximately 5 % of injured people and accounts for 24 % of traumatic injuries to abdominal organs. Surgical treatment remains the gold standard in unstable patients with gunshot and stab wounds. Minimally invasive surgical treatment of kidney injuries, which is usually performed after laparoscopic diagnosis, at the II level of medical care becomes possible in the first hours after injury.

CASE PRESENTATION

We performed two laparoscopic nephrectomies caused by gunshot shrapnel damage to the kidney in a military mobile hospital at the II level of medical support. The time since the injury was 64 ± 16 min. The wounded were extubated after the operations, activated on the first day. In one case, the drain was removed on the third day, in the other - on the fourth day. During the monitored period (30 days) after the operation, there were no complications in both wounded.

CLINICAL DISCUSSION

Laparoscopic nephrectomy in gunshot damage to the kidney was characterized by presence of a retroperitoneal tense hematoma. When opened, there were signs of bleeding from the kidney parenchyma, difficulty of anatomical visualization of anatomical structures - ureter, renal artery and vein.

CONCLUSION

It is possible to perform endovideosurgical operations - laparoscopic nephrectomy in combat kidney injury at a military mobile hospital with available high-tech equipment at the II level of medical support (Role II), thus bringing highly specialized care closer to the wounded. We noted a better cosmetic effect after the laparoscopic operations.

Asiaticoside inhibits renal fibrosis development by regulating the miR-142-5p/ACTN4 axis

Renal fibrosis results in the progressive renal dysfunction and leads to chronic kidney disease (CKD) and ultimately end-stage renal disease. Asiaticoside was reported to regulate synaptopodin, desmin, nephrin, and podocin levels in adriamycin-induced nephropathy of rats. In this study, we found out that asiaticoside inhibited renal fibrosis in vitro and in vivo. Additionally, miR-142-5p was upregulated in in vitro and in vivo models of CKD. MiR-142-5p promoted the levels of collagen-I, collagen-IV, and fibronectin proteins. Additionally, miR-142-5p overexpression partly rescued the protective effect of asiaticoside on renal fibrosis. Mechanistically, miR-142-5p inhibited ACTN4 levels by binding with its 3´untranslated region, and further reduced its translation. Treatment of asiaticoside decreased miR-142-5p levels and increased ACTN4 levels. Rescue assays revealed that ACTN4 overexpression partially rescued the effect of miR-142-5p on renal fibrosis. Asiaticoside mitigated renal fibrosis by regulating the miR-142-5p/ACTN4 axis. In conclusion, asiaticoside inhibits renal fibrosis by regulating the miR-142-5p/ACTN4 axis. This novel discovery suggested that asiaticoside may serve as a potential medicine for renal fibrosis improvement.

Traumatic Kidney Injury: An Observational Descriptive Study

BACKGROUND

Trauma is a major cause of death and disability worldwide. Renal injuries account for 8-10% of abdominal trauma. We aimed to describe the incidence, presentation, and management of traumatic kidney injury in our institution.

METHODS

This is a retrospective analysis of all patients admitted with traumatic kidney injury at a level 1 trauma center between January 2014 and December 2017.

RESULTS

During a period of 3 years, a total of 152 patients with blunt renal trauma were admitted to a level 1 trauma center; 91% of these were males, with a mean age of 32.8 ± 13.7 years. Motor vehicle crashes accounted for 68% of cases, followed by fall from height (23%). Seventy-one percent of patients had associated chest injuries, 38% had pelvis injuries, and 32% had head injury. Associated abdominal injuries included the liver (35%) and spleen (26%). The mean abdominal abbreviated injury scale was 2.8 ± 1.0; and for those with severe renal injury, it was 3.9 ± 0.9. The mean injury severity score was 24.9 ± 13.7 (31.8 ± 14.2 with renal vs. 21.9 ± 12.9 without renal injury, p = 0.004). Most of the patients were treated conservatively (93%), including severe renal injuries (grades IV and V), and 7% had surgical exploration, mainly those with severe injuries (grades IV and V). The mortality rate was 11%.

CONCLUSIONS

High-grade renal injuries in hemodynamically stable patients can be managed conservatively. A multidisciplinary approach coordinated by trauma, urology, and radiology services facilitates the care of these patients in our trauma center.

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.

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.

Salvageability of kidney in Grade IV renal trauma by minimally invasive treatment methods

Context:

Renal trauma is increasingly being managed conservatively. Grade I-III injuries are managed conservatively whereas Grade V injuries may end in surgery. Managing Grade IV renal trauma is individualized and managed accordingly.

Aims:

To evaluate retrospectively all Grade IV renal injuries managed in our institute over five years and to review the available literature.

Settings and Design:

Reviewing the records of patients who sustained renal trauma and study all Grade IV renal injuries.

Materials and Methods:

We retrospectively analyzed all Grade IV renal injuries (16) managed at our institute between July 2008-August 2013. All patients were treated conservatively initially by hemodynamic stabilization, strict bed rest, if required endoscopic procedures. These patients were followed up with CECT.

Statistical analysis:

Descriptive statistics was performed using Microsoft excel spreadsheet 2007. Continuous data were described as mean and range. Categorical data was described as percentages.

Results:

Sixteen patients with Grade IV renal injury were included in the study. All patients had gross hematuria and 15 had urinary extravasation. D-J Stenting was done in 7 patients; perinephric tube drainage with D-J stentingwas done in 2 patients. One required selective upper pole arterial embolisation. Nephrectomy was not required in any of the patients. In the follow-up period, no patient had delayed complications.

Conclusions:

Successful conservative management of Grade IV renal trauma requires constant monitoring both clinically and radiologically, and if properly managed, kidneys can be salvaged in all stable patients as reinforced by our study.

Superselective transcatheter renal artery embolization for the treatment of hemorrhage from non-iatrogenic blunt renal trauma: report of 16 clinical cases

Objective

To explore the therapeutic efficacy and outcome of superselective transcatheter renal artery embolization for the treatment of hemorrhage from non-iatrogenic blunt renal trauma (BRT).

Methods

Sixteen patients who received superselective transcatheter renal artery embolization for non-iatrogenic BRT hemorrhage between January 2003 and December 2012 were reviewed retrospectively. Spring steel coils with gelatin sponge particles were used to embolize branches of the renal artery in 15 patients with injuries to the segmental or distal renal arteries; super-selective internal iliac artery branch embolization was used to occlude hemorrhage from the branch of the renal artery in two patients with pelvic fracture complicated with internal iliac artery branch laceration; and balloon catheter occlusion was used to embolize the branch of the renal artery in one patient with renal artery trunk laceration.

Results

Embolization was achieved successfully in a one-stop procedure in all cases. The patient who received balloon catheter occlusion for renal artery trunk laceration was transferred immediately to surgery for emergency nephrectomy. Another patient died of intracranial trauma 1 day after surgery, although macroscopic hematuria disappeared at the time. Macroscopic hematuria disappeared within 1 day after surgery in the other 14 patients. Follow-up visits at times ranging from 6 months to 9 years after the procedure showed normal renal function without evidence of complications in all surviving patients.

Conclusion

Superselective transcatheter renal artery embolization is an effective minimally invasive therapy for the treatment of BRT hemorrhage.

Management of blunt renal injury in a level 1 trauma centre in view of the European guidelines

BACKGROUND

Debate continues about the optimal management strategy for patients with renal injury.

PURPOSE

To report the diagnostics and treatment applied in a level 1 trauma centre and to compare it to the recommendations of the European Association of Urology guidelines concerning blunt renal injury.

METHODS

The management of all patients with blunt renal injury, admitted to the level 1 trauma centre of the Academic Medical Centre, between January 2005 and December 2009 was reviewed retrospectively.

RESULTS

Median age and ISS of the 186 included patients were 40 and 17 years respectively. All but one haemodynamically stable patients with microscopic haematuria received nonoperative management. Sixty percent of the haemodynamically stable patients with gross haematuria underwent CT scanning. Patients with grade 1-4 renal injury received nonoperative management. Additionally, two patients with grade 3-4 renal injury received angiography and embolization (A&E). One patient with grade 5 injury underwent renal exploration and two A&E. Seven of the 8 haemodynamically unstable patients underwent emergency laparotomy and in 2 patients, haemodynamically unstable because of renal injury, A&E was performed as an adjunct to surgical intervention.

CONCLUSIONS

In the present study, violation of the guidelines increased with injury severity. A&E can provide both a useful adjunct to nonoperative management and alternative to surgical intervention in specialised centres with appropriate equipment and expertise, even in patients with high grade renal injury. We advocate an update of the guidelines with a more prominent role of A&E.

A 10-year review of blunt renal artery injuries at an urban level I trauma centre

INTRODUCTION

Little consensus exists over the management of high-grade renal injuries, with continued debate over observation versus invasive surgery. Blunt renal artery injury (BRAI) is a high-grade injury that may result in renal dysfunction, hypertension, or failure.

MATERIALS AND METHODS

Management of BRAI at a level I trauma centre during a decade was retrospectively reviewed to determine incidence, assess management strategy, and evaluate hospital outcomes. Data collected included demographics, injury details, standardised scoring, renal injury grade, haemodynamic stability, diagnostic modalities, medical interventions, mortality, and hospitalisation length.

RESULTS

Thirty-eight BRAI patients (21 Grade IV and 17 Grade V injuries) were admitted, representing 0.16% of trauma admissions, and consisting primarily of young males. Ultrasonography and CT was performed in 92.1% and 76.3% of patients, respectively. Primary management included exploratory laparotomy in 42.9%, angiography and embolisation in 34.3%, and observation in 22.9%. Six nephrectomies and one revascularisation were performed. The incidence of BRAI and use of angiography are higher than those reported in previous studies.

CONCLUSION

Over the past decade, increased use of CT as a diagnostic tool for confirming renal injury in haemodynamically stable patients at our institution may have contributed to the increase in BRAI detection. Higher utilisation of angiography has enabled a more conservative approach. In this series, angiography had a success rate of 94.4%. Angiography and embolisation or observation with careful monitoring are viable management options in haemodynamically stable patients with isolated BRAI.