Initial radiological findings associated with active bleeding control necessity and long term functional outcomes after isolated high grade blunt renal trauma

INTRODUCTION

To assess the predictors for conservative management failure and long term outcomes after isolated blunt high grade renal trauma (HGRT).

METHODS

 A retrospective analysis of patients with isolated blunt HGRT (renal trauma grade ≥ IV) was conducted. Patients' demographics, clinical presentation, laboratory and radiological investigations, and different lines of treatment were retrieved. The primary outcome was to assess the predictors of conservative treatment failure (need for active bleeding control e.g.: transarterial angioembolization (TAE) and/or surgical exploration). The secondary outcome was to assess the renal parenchymal volume (RPV) changes post HGRT in correlation with the different lines of management using CT-measured RPV. The difference in RPV ≥ 5% at follow up was considered significant.

RESULTS

The study included 63 patients, mean (SD) age was 35.1 (16.6) years. Conservative management was successful in 39 patients (62%), while the need for active bleeding control was required in 16 and 8 patients who underwent TAE and surgical exploration, respectively. Increased hematoma rim distance (HRD), laceration numbers > 3, parenchymal devascularization ≥ 25%, and presence of vascular contrast extravasation (VCE) were predictors for conservative treatment failure (P= 0.006, 0.02, 0.045 and 0.002, respectively). After a mean of 19 months follow up, patients were subclassified into 2 groups: patients with preserved RPV (28 patients) and patients with decreased RPV (29 patients). Renal parenchymal devascularization ≥ 25% was found a predictor for ipsilateral RPV decrease (P = 0.02).

CONCLUSION

Increased HRD, laceration numbers > 3, parenchymal devascularization ≥ 25%, and presence of VCE are findings that reflect the necessity for active bleeding interventions after isolated blunt HGRT. Parenchymal devascularization ≥ 25% is an independent factor for RPV deterioration. Neither the grade of renal trauma nor the type of treatment is a predictor for such deterioration.

Contemporary management of pediatric high grade renal trauma: 10 year experience at a level 1 trauma centre

BACKGROUND

Current guidelines advocating the conservative management of renal injuries in children are primarily extrapolated from adult series due to a dearth of evidence in the pediatric population.

OBJECTIVES

The aim of this study was to review our experience in the management of pediatric high-grade renal trauma and to clarify the role of conservative management in this cohort of patients.

STUDY DESIGN

The Alberta Trauma Registry (ATR) is a comprehensive web-based registry which functions to prospectively collect data on all trauma patients in the province who sustain a severe injury (i.e. Injury Severity Score (ISS) ≥12). The ATR was used to identify all pediatric patients who attended hospitals within the Edmonton region with high grade renal injuries (grade III-V) between January 2006 and December 2018. Hospital records and imaging were reviewed to identify patient demographics, mechanism of injury, AAST grade, haemodynamic stability, associated injuries, management, length of hospital stay (LOS), complications, and follow-up outcomes.

RESULTS

A total of 53 children (38 boys, 15 girls) were identified with a mean age of 13 years (1-16). The mechanism of injury was blunt trauma in 92.5% (49/53) of cases (Supplementary Table). AAST grade distribution was 37.8% Grade III (20/53), 49% Grade IV (26/53) and 13.2% Grade V (7/53). All Grade III injuries were successfully managed conservatively. Overall 11 patients with Grade IV/V injuries required urological intervention (ureteral stenting (5 patients), angioembolization (4 patients), bladder washout with clot evacuation (1 patient), emergency nephrectomy (3 patients)). The overall renal salvage rate was 92.4% (49/53).

DISCUSSION

Our series confirms the safety of expectant management in high grade pediatric renal trauma. All grade III injuries in our study were managed conservatively without the need for intervention. This suggests that these injuries may be managed safely outside of designated trauma centres. One third of children with grade IV/V injuries required intervention. Therefore we recommend that patients with these injuries are transferred to specialized units with the capacity to provide such procedures if required.

CONCLUSION

This study supports the conservative management of pediatric renal trauma in the setting of high-grade injury. Expectant management was associated with acceptable rates of intervention and excellent renal salvage rates.