Pediatric Surgery International (2018) 34:1183–1187

https://doi.org/10.1007/s00383-018-4355-9

ORIGINAL ARTICLE

Pediatric renal injury: which injury grades warrant close follow-up

Lindsey B. Armstrong1 · David P. Mooney1

Accepted: 21 September 2018 / Published online: 27 September 2018

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Purpose  Most children who suffer renal trauma recover fully; however, some have long-term consequences. We sought to
determine what grades of injury carry concern for complication and warrant close follow-up.
Methods  Data on children with grade II or higher renal injuries from a single center over 20 years were reviewed. Demo-
graphics, presenting symptoms, lab values, clinical course, management, and follow-up data were analyzed.
Results  One hundred seventy-one children suffered renal injuries: 75% boys, aged 11.6 ± 3.5 years. Falls-54 and sports-43
were leading injury mechanisms. Presentations included pain only-61, pain and hematuria-28 and hematuria alone-11. Eight
had pre-existing abnormalities. Injury grades were: grade II-88 (52%), grade III-49 (29%), grade IV-28 (16%), and grade
V-6 (3%). No grades II or III patient underwent intervention or suffered sequelae. Grade IV patients underwent: stenting-5,
surgery-2, embolization-1, and drainage-1. Grade V patients underwent: surgery-2, embolization-1, and drain-1. Two grade
IV patients underwent late interventions: nephrectomy-1 and stenting-1. Six patients, all grades IV–V, were newly hyper-
tensive at follow-up.
Conclusion  Grades II and III renal injuries carry a low risk of complication and repeat imaging and close follow-up are
likely not necessary. However, grades IV and V injuries carry a meaningful risk of adverse outcome and close follow-up is
warranted.

Keywords  Renal injury · Pediatric · Outcome · Injury grade · Follow-up

Introduction repeat imaging [7]. A review of blunt pediatric renal injury

In general, renal injury may be seen in up to 5% of trauma
patients presenting to a hospital [1, 2]. The kidney is the
most commonly injured genitourinary organ [3], with blunt
mechanisms being more common than penetrating [4]. Sev-
enty-five percent of renal injuries occur in patients less than
44 years of age [4]. Children are at higher risk of renal injury
secondary to decreased perinephric fat, smaller surrounding
supportive musculature, and a less ossified rib cage [5, 6].
Nonoperative management of hemodynamically stable
patients with a renal injury is accepted in the adult and
pediatric literature [6]. Nonoperative management details
vary across institutions but typically include bed rest, serial
abdominal exams, recurrent laboratory analyses and often
* David P. Mooney
david.mooney@childrens.harvard.edu
1
Department of Surgery, Boston Children’s Hospital
and Harvard Medical School, 300 Longwood Avenue,
Boston, MA 02115, USA
care demonstrated broad use of nonoperative management
but variable practice strategies with little attention to injury
grade specific management for both acute care and follow-
up [8]. We sought to determine if outcome was dependent
upon injury grade in order to better direct follow-up efforts.
Methods
After obtaining Institutional Review Board approval, the
trauma registry of a level 1 Pediatric Trauma Center was
reviewed. Data on all children identified with a blunt renal
injury between 1994 and 2014 were extracted, including:
age, gender, mechanism of injury, imaging studies per-
formed, all injury diagnoses, all procedures performed,
hospital length of stay and any complications. Patients’
electronic medical records were surveyed for post-discharge
encounters, imaging studies performed, and complications
or interventions related to their renal injury. Injuries were
graded using the American Association for the Surgery of

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Trauma (AAST) Organ Injury Scoring Scale for renal inju-
ries [9]. For this paper, grades II and III are referred to as
low grade and grades IV and V as high grade.
Results
Demographics
One hundred seventy-one patients with a grade II or greater
blunt renal injury were identified over the 20-year study
period. Median (IQR) age was 12 (8–15) years and 75%
were males. Eighty-eight children presented with grade II
(52%), 49 (29%) grade III, 28 (16%) grade IV, and 6 (3%)
grade V. Sixty-eight (40%) children had associated injuries,
most commonly spleen followed by liver and median (IQR)
Injury Severity Score was 9 (5–17). Median (IQR) time to
most recent medical follow-up was 6 months (4 years).
Eight (4.7%) children had pre-existing kidney anoma-
lies: four with undiagnosed ureteropelvic junction stenosis,
and one each had an underlying glomerulonephropathy, a
horseshoe kidney, an existing renal cell carcinoma diagnosed
at the time of injury, and a hypoplastic kidney. A fall was
the most common mechanism of injury (32%), followed by
sports (25%), and bicycles crashes (16%) (Fig. 1).
Hematuria
A urinalysis (UA) was performed on 159 (93%) patients
including all those with high-grade (IV–V) injuries. Of those
with a UA, gross hematuria, more than 50 red blood cells
per high powered field and/or a urine dipstick reading of
3 +, was present in 74% of patients with grade II injuries,
90.5% of grade III, 95.8% of grade IV, and 100% of grade
V patients (Fig. 2).
Other
11%
Pedestrian
Falls
6%
32%
MVA
10%
Bicycle
Crash
16% Sports
25%
Fig. 1  Mechanism of injury. The percentage of children with renal
injuries who were injured by the mechanisms of injury presented
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Pediatric Surgery International (2018) 34:1183–1187
Hematuria by Grade of Renal Injury
100
90
80 Gross, 3+
70 or > 50
Percentage
60
50
40 Less or
30 Neg
20
10
0
2 3 4 5
Grade of Renal Injury
Fig. 2  The percentage of children with hematuria by grade of renal
injury. Grade of renal injury the American Academy for the Surgery
of Trauma Solid Organ Injury grade, Gross visible hematuria, 3 + a
urine dipstick reading of 3 or higher, >  50 more than 50 red blood
cells present in the urine per high powered field
Intervention
Thirteen (7.6%) of the 171 patients underwent some form
of procedural intervention for their renal injury during
their primary admission (Table 1). Nine (32%) of 28 grade
IV patients and four (66%) of 6 grade V patients under-
went intervention. No patient with a grade II or grade III
injury underwent intervention related to their renal injury.
One patient with a grade V injury underwent renal arterio-
gram for ongoing hemorrhage noted on computed tomog-
raphy (CT) angiogram, but the hemorrhage had stopped
and the patient stabilized without further intervention. Six
(21%) children with grade IV injury underwent interven-
tion for urine extravasation. Five underwent cystoscopy
with placement of a double J ureteral stent. The other
patient had a percutaneous nephrostomy drain placed.
Three patients required emergent surgery for hemo-
dynamic instability and concern for active hemorrhage.
All of these patients had grade IV or V injury. Two of
the operations were performed at outside hospitals imme-
diately prior to transfer. One patient underwent partial
nephrectomy for a grade V renal injury. Of note, his con-
tralateral kidney was hypoplastic. He was transferred to
our hospital on postoperative day 2. A different grade V
renal injury patient underwent emergent abdominal explo-
ration, four quadrant packing and temporary abdominal
closure at another institution, and then operating room
to operating room transfer to our facility where he went
underwent nephrectomy secondary to persistent hemor-
rhage. The last patient suffered a grade IV injury and went
directly to the operating room at our hospital where he was
found to have a fractured kidney with large perinephric
hematoma contained by Gerota’s fascia. His abdomen was
packed, he was stabilized and underwent angiography in
Pediatric Surgery International (2018) 34:1183–1187 1185

Table 1  Acute intervention by AAST grade N LOS (days) Embolized Stent Drain Nephrectomy Other
grade of injury (partial or full) opera-
tion

II 88 6 0 0 0 0 0
III 49 5.5 0 0 0 0 0
IV 28 9 1 5 1 0 2
V 6 9.6 1 0 1 2 0

AAST Grade the American Academy for the Surgery of Trauma Solid Organ Injury grade, N number, LOS
length of hospital stay, Embolized number of patients undergoing percutaneous embolization of a renal
blood vessel, Stent number of patients undergoing ureteral stent placement, Drain number of patients
undergoing percutaneous placement of a renal pelvic drain

interventional radiology for possible embolization, but no
ongoing hemorrhage was noted.
Operations after discharge
Children that underwent cystoscopic double J stent place-
ment returned to the operating room as outpatients for
removal of the stent (Table 2). One patient with grade IV
injury who did not undergo intervention during her admis-
sion underwent later stent placement, subsequent stent
exchange, and eventual stent removal, all occurring after
initial discharge.
One patient with a grade IV injury underwent cystoscopy
and stent placement during the initial inpatient stay with
eventual stent removal after discharge. The patient was then
lost to follow-up, only to present 4 years later with marked
hydronephrosis and poor renal function secondary to an
ureteropelvic junction stenosis and underwent nephrectomy.
Hypertension
Sixty-four (37%) of the patients had some form of follow-up
blood pressure measurement recorded in the medical record
at more than 4 weeks post discharge, with a mean follow-up
of 3.48 ± 0.37 years. However, of the 34 high-grade injury
patients, 21 (62%) had follow-up blood pressure monitor-
ing. Hypertension was defined as a systolic blood pressure
greater than the 90th percentile for age and gender on at
least two separate occasions. No grade II or III patient was
hypertensive. Six patients: three grade IV (10.7%) and three
grade V (50%) developed de novo hypertension, all within
2 months of their injury. Only one patient was reported as
hypertensive while inpatient. Two of the six were managed
medically. The other four patients were noted to be hyperten-
sive at follow-up visits but were not started on antihyperten-
sive medication. In two of these patients, the hypertension
resolved spontaneously and the other two children were lost
to follow-up.
Follow‑up
Post-injury follow-up was variable among patients, was
dictated by the inpatient provider and the injury severity.
Median (IQR) time to most recent clinical follow-up was
6 months (4 years). While most patients received follow-
up in the trauma surgery clinic, 34 (20%) were seen by a
urologist. Imaging was obtained when indicated based on
clinical presentation or based on determined need given the
original injury imaging. Fifty-five (32%) patients underwent
some form of follow-up imaging. The majority of follow-up
imaging was ultrasound; however, 8 (5%) had a CT scan. Six
percent of the patients had a radionuclide or radioisotope
scan performed at some point after injury to assess renal
morphology, scarring and/or function. As stated previously,

Table 2  Delayed intervention AAST grade N Stent place- Stent removal Drain Nephrectomy New HTN
and outcome by grade of injury ment (full)

II 88 0 0 0 0 0
III 49 0 0 0 0 0
IV 28 2 7 1 1 3
V 6 0 0 0 0 3

AAST Grade the American Academy for the Surgery of Trauma Solid Organ Injury grade, N number, Stent
Placement number of patients undergoing ureteral stent placement after the acute period, Stent Removal
number of patients undergoing removal of a percutaneous placement of a renal pelvic drain after the acute
period, Drain number of patients undergoing percutaneous placement of a renal pelvic drain after the acute
period, New HTN patients found to be hypertensive after the acute period

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post injury blood pressure monitoring was inconsistent or
not well documented.
Of the patients diagnosed with hypertension, two of them
had DMSA scans obtained at follow-up while the others
were evaluated with ultrasound. One patient did not have
any imaging performed post-injury.
Discussion
Blunt renal trauma in children is associated with favorable
outcomes and the majority of patients do not undergo inter-
vention. In this group of patients, we found that those with
grade II and III injuries did not undergo procedural interven-
tion and none were found to have long-term complications.
Those with grade IV and V injuries were more likely to
undergo acute intervention and were at greater risk of later
complications.
In order to provide a common structure for research, the
AAST Organ Injury Grading system was devised in 1987.
The original classification system was based upon opera-
tive findings and was later revised to include CT images in
patients who did not undergo operation [9]. The renal injury
grading scale includes grades I–V with grade I (contusion
associated with hematuria or subcapsular nonexpanding
hematoma without parenchymal lesion) being least severe
and grade V (completely shattered kidney or complete
devascularization with avulsion of the renal hilum) being
most severe. Scoring systems such as this have allowed us
to more accurately classify renal injuries and to determine
if patient outcomes are dependent upon injury grade. Sono-
graphic imaging was not considered in the development
of the AAST grading system and differences between this
CT-based grading system and sonography may need to be
considered in the future.
Using the AAST grading scale, classifying grade of injury
as low versus high, we found a large incongruence in out-
come that can be used to direct follow-up in patients with a
significant risk of later complications, saving the children at
low risk from unnecessary follow-up appointment or imag-
ing. None of the children with low-grade injury underwent
a procedural or surgical intervention while inpatient or dur-
ing follow-up. In addition, none of these children developed
post injury hypertension; however, vital sign documentation
was limited. In comparison, nearly 40% of the patients with
high-grade injury underwent some form of intervention dur-
ing their initial hospitalization, ranging from percutaneous
drain placement to exploratory laparotomy and nephrectomy.
Among the 34 high-grade patients, ten interventions were
performed during the follow-up period.
Management of renal pelvic urine leaks poses a spe-
cific debate as urinomas may be asymptomatic and many
are self-resolving [10]. In addition, no universally accepted
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Pediatric Surgery International (2018) 34:1183–1187
management protocol exists for treatment; thus it is often
dictated by surgeon preference. In our experience, the chil-
dren who underwent intervention, whether stent or drain
placement, had all demonstrated a concerning increase
in the size of the urinoma on imaging. When a stent was
placed, the child later returned to the operating room, at least
once, for stent exchange or removal. No child had complica-
tions related to stent removal or the concomitant anesthetic,
though one child underwent nephrectomy years after stent
removal, possibly secondary a recalcitrant ureteropelvic
stenosis.
In our study we did not conduct routine functional follow-
up assessments of the injured renal units. Kumar et al., ana-
lyzing the function of 32 injured kidneys using DMSA scans
3 months after injury, found that function was well preserved
for grade I-III injuries. However, patients with grades IV
and V injuries did suffer a decrease in renal function [10].
The observation that renal function, as assessed by DMSA
scan at 3 months, was preserved in grades I–III injuries, was
confirmed by Keller et al. [11]. They also noted long-term
preservation of renal function 1 year post injury [12].
The exact probability of hypertension after renal trauma
in children is unknown. In a recent pediatric single-center
review by Fuchs et al. 4 of 62 (6.5%) children with grades
III–V renal injury developed post injury hypertension [13].
When only including patients with grades IV and V injuries,
the rate of hypertension was 3 of 41 (7.3%). In our study, 6 of
83 (7.2%) grades III–V patients and 6 of 34 (17.6%) grades
IV and V developed hypertension. Fuchs’ study included
only one grade V patient, who was one of the hypertensive
patients. However, in both studies follow-up blood pres-
sure monitoring was inconsistent with approximately 60%
of patients receiving monitoring; therefore, they may pro-
vide a sense of the incidence but not a clear number. Future
research should examine the relationship between findings
on post-injury sonography and DMSA scanning, and adverse
outcomes such as hypertension.
Our study is limited by its retrospective nature and con-
sequently certain data points are missing on some patients.
Several patients did not have a UA performed and more than
half of the patients did not have blood pressure information
available after discharge. Follow-up was more thorough for
high-grade injuries, but was still not complete.
Conclusion
The AAST grade of kidney injury can be a useful predic-
tor of the need for acute intervention and the risk of later
complications. Close follow-up, including blood pressure
monitoring, is important for children with grades IV and V
injuries, but is likely not necessary for children with lesser
grades of injury.
Pediatric Surgery International (2018) 34:1183–1187 1187
Funding  This study was unfunded.
Compliance with ethical standards  6. Wessel LM, Scholz S, Jester I, Arnold R, Lorenz C, Hosie S,
Conflict of interest  The authors have no real or potential conflicts of
interest to disclose.
Ethical approval  This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent  This data review was determined by our IRB to
be exempt from any requirement to obtain informed consent from the
involved patients.
10. Kumar K, Singh S, Mittal BR, Singh S, Mandal A (2017) Recov-
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