International Journal of Surgery 74 (2020) 13–21

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International Journal of Surgery

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Traumatic kidney injuries: A systematic review and meta-analysis T

a,∗ a a b
Patrizio Petrone , Javier Perez-Calvo , Collin E.M. Brathwaite , Shahidul Islam ,
D'Andrea K. Josepha
a
Department of Surgery, NYU Langone Health - NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, NY, USA
b
Department of Biostatistics, NYU Langone Health - NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, NY, USA

ARTICLE INFO ABSTRACT

Keywords: Background: Traumatic kidney injury is an infrequent event with a wide range of injury patterns. The aim of this
Kidney injuries paper is to review the incidence, mechanisms of injury, diagnostic methods, and therapeutic indications of renal
Trauma injury according to the most recent evidence and to perform an analysis of mortality rates on these patients.
Diagnosis Objectives: To perform a systematic review of the literature and a meta-analysis on traumatic kidney injuries.
Management
Data sources: A literature search was performed using PubMed, Embase, and Scopus databases. Articles pub-
lished in English, French and Spanish were selected from 1963 to 2018. MeSH terms utilized were renal trauma,
kidney trauma, blunt renal trauma, and penetrating renal trauma.
Study participants: The eligibility criteria included only original and human subject articles. Articles not invol-
ving human patients, cancer related, review articles, surveys, iatrogenic injuries, pediatric patients, and case
reports were excluded from this search.
Results: Forty-six articles met the inclusion criteria of which 48,660 patients were identified and included in this
review. Gender was reported in 32,918 cases, of which 75.3% of patients were male with a mean age of 33 years.
Of the 44,865 patients where the mechanism of injury was described, we identified 36,086 (80.5%) patients that
sustained blunt trauma, while 8,779 (19.5%) were due to penetrating mechanisms. Twenty one series with a
total of 31,689 patients included the mortality rate. Overall mortality rate with exact binomial 95% confidence
interval estimated via random effects model was 6.4% (4.8%–8.4%).
Conclusions: Non-operative management has become the standard in renal trauma management with good re-
sults in morbidity and mortality. This has resulted in a decrease in the number of unnecessary iatrogenic ne-
phrectomies and potential improvement in a patient's quality of life. When an invasive treatment is necessary,
angioembolization for active bleeding or nephrorrhaphy is usually sufficient.

1. Introduction
Renal injury, although uncommon, is not rare. Diagnosis and
treatment of these injuries require an extensive knowledge of the ret-
roperitoneal region. These injuries can present with different patterns,
which often entails complex diagnostic and therapeutic evaluation. The
purpose of this review is to describe the renal trauma characteristics
and treatment modalities based on the most recent literature evidence.
2. Methods
2.1. Data sources and search strategy
A literature search was performed using Medline, Pubmed, Embase,
and Scopus. MeSH terms utilized were renal trauma, kidney trauma, blunt
renal trauma, and penetrating renal trauma. Articles published in English,
French and Spanish were selected from the last 55 years (1963–2018). The
authors attempted to register this systematic literature review in PROSP-
ERO. This work has been reported in line with PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR
(Assessing the methodological quality of systematic reviews) Guidelines.
2.2. Study selection criteria
Only original and human subject articles were included, both pro-
spective and retrospective descriptive studies. Articles excluded were
those not involving human patients, cancer related, iatrogenic injuries,
pediatric patients, and case reports.

∗
Corresponding author. NYU Long Island School of Medicine, Department of Surgery, NYU Langone Health, NYU Winthrop Hospital, 222 Station Plaza North, Suite
300, Mineola, NY, 11501, USA.
E-mail addresses: patrizio.petrone@nyulangone.org, patrizio.petrone@gmail.com (P. Petrone).

https://doi.org/10.1016/j.ijsu.2019.12.013
Received 2 October 2019; Accepted 19 December 2019
Available online 21 December 2019
1743-9191/ © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
P. Petrone, et al. International Journal of Surgery 74 (2020) 13–21

Table 1
Incidence by author, gender and age.
Author and year (total of patients) Male, n (%) Female, n (%) Average age

Nation et al. [37], 1963 (258) 188 (73) 70 (27) 27

Rohner et al. [38], 1971 (61) N/A N/A N/A
Lang et al. [39], 1971 (74) N/A N/A N/A
Del Villar et al. [24], 1972 (100) N/A N/A N/A
Cass et al. [40], 1973 (54) 43 (79.6) 11 (20.3) N/A
Peterson et al. [18], 1973 (109) 92 (84.4) 17 (15.6) N/A
Bogash et al. [41], 1974 (65) N/A N/A N/A
Bergqvist et al. [42], 1983 (417) N/A N/A N/A
Cass et al. [43], 1985 (513) 392 (76.6) 121 (73.4) N/A
Presti et al. [2], 1989 (18) 17 (94.4) 1 (5.6) N/A
Nash et al. [50], 1995 (2,521) N/A N/A N/A
Baverstock et al. [67], 2001 (227) 189 (75) 56 (25) 35
Santucci et al. [34], 2001 (2,467) N/A N/A N/A
Dobrowolski et al. [3], 2002 (887) N/A N/A N/A
Saidi et al. [4], 2004 (105) 87 (83) 18 (17) 29
Kansas et al. [64], 2004 (93) 86 (93) 7 (7) 28
Rambeaud et al. [15], 2005 (45) 37 (83) 8 (17) N/A
Habrat et al. [6], 2005 (324) N/A N/A N/A
Kuan et al. [8], 2006 (8.465) 6,247 (73.8) 2,217 (26.2) N/A
Shariat et al. [36], 2007 (423) 320 (75.5) 104 (24.5) N/A
Dunfee et al. [29], 2008 (54) 36 (67) 18 (33) 35
Nuss et al. [55], 2009 (52) 39 (75) 13 (25) 30
García et al. [12], 2009 (106) 83 (78.3) 23 (21.7) 30
Tasian et al. [9], 2010 (67) 62 (93) 5 (7) 28
Aragona et al. [60], 2012 (45) 37 (82) 8 (18) N/A
McGuire et al. [53], 2011 (117) 93 (77.5) 24 (22.5) 28
Van Der Vlies [5], 2012 (186) 130 (70) 56 (30) 40
Buckley et al. [31], 2011 (3.580) N/A N/A N/A
Sugihara et al. [7], 2012 (320) 230 (72) 90 (28) 41
Shoobridge et al. [47], 2013 (320) 243 (76) 77 (24) 31
Figler et al. [35], 2013. (84) 54 (64) 30 (36) 33
Van Der Wilden [14], 2013 (206) 154 (75.7) 52 (24.5) 36
Hardee et al. [28], 2013 (126) N/A N/A N/A
Patel et al. [16], 2015 (320) 238 (74.3) 82 (25.6) 34
McPhee et al. [68], 2015 (36) 27 (75.0) 9 (25) 28
Bjurlin et al. [10], 2017 (19,572) 14,858 (75.9) 4,714 (24.1) 38
Broska et al. [13], 2016 (38) 34 (89.5) 4 (10.5) 27
May et al. [57], 2016 (47) N/A N/A 37
Winters et al. [65], 2016 (636) 33 (70) 14 (30) 31
Hampson et al. [69], 2018 (408) 352 (85.2) 56 (14.8) 31
Burns et al. [70], 2017 (48) 32 (67) 16 (33) 43
Terrier et al. [17], 2017 (395) N/A N/A N/A
Colaco at al [11], 2019 (4,296) N/A N/A N/A
Keihani et al. [59], 2018 (431) 341 (79) 90 (21) 34
Phan et al. [66], 2018 (97) 71 (73) 26 (27) 35
Joseph et al. [58], 2018 (36) 9 (25) 27 (25) 36
Total (48,660/32,918) 24,854 (75.3) 8,064 (24.6) 33

Total number of patients found was 48,660; of that, total gender was reported in 32,918.N/A: Not Available.

2.3. Data extraction
The first author (PP) supervised the entire process from the selection
of the qualifying articles to the way of the extraction took placed. A set
of data was independently extracted by one international research
fellow (IRF), and then verified by PP. In turn, PP extracted the second
set of data, and then it was verified by IRF. The data extracted from the
articles included in this review was performed using a data extraction
table with the following categories: Author, year of publication, type of
study, number of patients, age, gender, Injury Severity Score (ISS),
mechanism of injury (blunt vs. penetrating), injury degree based on the
American Association for the Surgery of Trauma Organ Injury Scale
(AAST-OIS), modality of kidney injury diagnosis, and type of treatment.
available aggregated data from 37 studies. In computing OR and 95%
CI, we came across zero cell count for a number of studies. Hence, we
used Haldane-Anscombe correction (0.5 was added to each of the cells)
to adjust the cell counts. Mortality rates and exact binomial confidence
intervals were computed using available aggregated data from 21 stu-
dies. Random effects models were used to assess the overall effects.
Heterogeneity among the studies was assessed using Q test and quan-
tified using inconsistency (I [2]). Forest plots were used to depict
overall and individual study estimates. Meta-Analysis was performed
using SAS 9.4 (SAS Institute, Cary, NC).
3. Results

2.4. Statistical methods
Demographics characteristics such as gender and age by study were
presented using frequency (percentage) or mean as appropriate. Odds
ratios (OR) with 95% confidence intervals comparing blunt mechanism
among operative and non-operative groups were computed using
Forty-six series met criteria for selection of which 48,660 patients
were identified (Table 1). The PRISMA flow diagram is shown in
Fig. 1.
An assessment of risk of bias was performed per each individual
study, using the Newcastle - Ottawa Quality Assessment Scale for both
case control studies and cohort studies as valid evaluation tools.

14
P. Petrone, et al.
Fig. 1. PRISMA 2009 flow diagram.
3.1. Incidence
Traumatic renal injury is infrequent, with rates between 1.4% and
3.2% of trauma victims [1]. This low incidence compared to other
traumatic abdominal injuries is likely due to its retroperitoneal loca-
tion, which also hinders and delays diagnosis. Our review found that
gender was reported in 32,918 cases, of which 75.3% of patients were
male with a mean age of 33 years (Table 1).
3.2. Mechanism of injury
The most common mechanism for renal injury is blunt trauma,
although there are a few reports such as Presti et al. [2] that suggest a
higher frequency of penetrating renal injury than described in the
literature. Blunt abdominal trauma is responsible for 95%–100% of
the renal injuries in European [3–6] and Japanese [7] studies, while
penetrating trauma dominates in studies from United States [2,8–11]
and South America [12,13]. Of the latter, the incidence of penetrating
approaches 88% [2]. Of the 44,865 patients where the mechanism of
injury was described, we identified 36,086 (80.5%) patients that
sustained blunt trauma, while 8,779 (19.5%) were due to penetrating
mechanisms (Table 2). According to recent published renal trauma
series, the most frequent mechanism of injury are motor vehicles
collisions, followed by falls, assaults and other less frequent causes
[4–17]. The overall odds ratio (95% CI) comparing blunt trauma be-
tween operative and non-operative groups computed via random ef-
fects model was 0.03 (0.02–0.04), which suggest that the odds of in-
jury with blunt trauma undergoing surgery was 85% lower compared
to non-operative. The model found that I [2] was 27.6 (p < 0.159)
(Fig. 2).
15
International Journal of Surgery 74 (2020) 13–21
3.3. Associated injuries
Peterson et al. [18] reported isolated injury in only 28% of the cases
of which up to 48% of the time was due to blunt trauma. Isolated renal
injury was present in 8% of patients with penetrating injury. When
there is a combined renal and colonic injury, penetrating is the most
common mechanism of injury (96.5%) [19]. In our review, 22 series
referred to the presence of associated injuries in 35% (8,356/23,830) of
the patients without significant changes in these numbers in recent
years. This suggests that traumatic mechanisms remain similar to those
of decades ago.
3.4. Diagnosis
Diagnosis of renal trauma is made with a high suspicion for the
injury. When a trauma patient is examined, careful evaluation of the
mechanism of injury and clinical presentation must be performed [20].
In general, while hematuria is present in 95% of patients with renal
trauma, its absence does not rule out injury [21]. Prompt diagnosis is
key as the injury may be life threatening. Imaging studies, such as
Focused Abdominal Sonography for Trauma (FAST), allow a general
abdominal preview and helps to rule out potentially fatal injuries but it
is limited by its ability to access the retroperitoneum. Moreover, the
FAST does not allow for renal trauma classification and could miss some
injuries [22,23]. In the past, when diagnostic resources were less
available, an intravenous urography was performed and if extravasa-
tion was seen or a lesion of the calyces or a decrease in renal function,
an arteriography was performed. This process allowed for the surgical
decision making in the management of the renal injury [24]. This
method of diagnosing injury has been replaced by more reliable tech-
niques but is sometimes utilized when resources are limited, or when it
P. Petrone, et al. International Journal of Surgery 74 (2020) 13–21

Table 2
Mechanism of renal injury.
Author and year (total of patients) Blunt, n (%) Penetrating, n (%)

Nation et al. [37], 1963 (258) 224 (0.49) 34 (0.07)

Rohner et al. [38], 1971 (61) 0 61 (0.13)
Del Villar et al. [24], 1972 (100) 93 (0.20) 7 (0.01)
Cass et al. [40], 1973 (54) 39 (0.08) 15 (0.03)
Peterson et al. [18], 1973 (109) 58 (0.12) 51 (0.11)
Bogash et al. [41], 1974 (65) 65 (0.14) 0 (0)
Cass et al. [43], 1985 (513) 453 (0.99) 60 (0.13)
Presti et al. [2], 1989 (18) 2 (0.004) 16 (0.03)
Nash et al. [50], 1995 (2,521) 2,245 (4.94) 276 (0.60)
Baverstock et al. [67], 2001 (227) 212 (0.46) 15 (0.03)
Dobrowolski et al. [3], 2002 (887) 862 (1.89) 25 (0.05)
Saidi et al. [4], 2004 (105) 105 (0.23) 0
Kansas et al. [64], 2004 (93) 93 (0.20) 0
Habrat et al. [6], 2005 (324) 315 (0.69) 9 (0.02)
Kuan et al. [8], 2006 (8.465) 6,891 (15.18) 1,574 (3.46)
Shariat et al. [36], 2007 (423) 320 (0.70) 103 (0.22)
Dunfee et al. [29], 2008 (54) 44 (0.09) 10 (0.02)
Nuss et al. [55], 2009 (52) 47 (0.10) 5 (0.01)
García et al. [12], 2009 (106) 78 (0.17) 28 (0.06)
Tasian et al. [9], 2010 (67) 43 (0.09) 24 (0.05)
McGuire et al. [53], 2011 (117) 117 (0.25) 0
Van Der Vlies [5], 2012 (186) 186 (0.40) 0
Buckley et al. [31], 2011 (3,580) 3,115 (6.86) 465 (1.02)
Sugihara et al. [7], 2012 (320) 304 (0.67) 16 (0.03)
Shoobridge et al. [47], 2013 (320) 307 (0.45) 13 (0.02)
Van Der Wilden [14], 2013 (206) 206 (0.45) 0 (0)
Hardee et al. [28], 2013 (126) 122 (0.26) 4 (0.008)
Patel et al. [16], 2015 (320) 320 (0.70) 0
McPhee et al. [68], 2015 (36) 28 (0.06) 8 (0.01)
Bjurlin et al. [10], 2017 (19,572) 15,418 (33.98) 3,825 (8.43)
Broska et al. [13], 2016 (38) 23 (0.05) 15 (0.03)
Winters et al. [65], 2016 (636) 549 (1.21) 87 (0.19)
May et al. [57], 2016 (47) 47 (0.10) 0
Hampson et al. [69], 2018 (408) 160 (0.35) 248 (0.54)
Burns et al. [70], 2017 (48) 48 (0.10) 0
Colaco et al. [11], 2019 (4.296) 2,635 (5.81) 1,661 (3.66)
Keihani et al. [59], 2018 (431) 308 (0.67) 123 (0.27)
Total: 45,190/44,865 36,086 (80.5) 8,779 (19.5)

Total number of patients found was 45,190; of this total, the mechanism of injury was detailed in 44,865.
N/A: Not Available.

is necessary to selectively visualize a renal arterial region as is the case
of arteriography [25].
In the last few decades Computerized Tomography (CT) has im-
proved exponentially and allows for the ability to identify vascular,
parenchymal and collecting systems in detail [26]. In fact, the Amer-
ican Urology Association (AUA) has established the CT as a gold stan-
dard for the diagnosis of renal injuries, and recommends this as the
choice of diagnostic method as long as the patient is hemodynamically
stable [27,28]. CT sensitivity is around 93%, with a specificity of 100%.
If non-operative management of renal trauma is decided, it is not ne-
cessary to routinely perform serial CT scans; however, this decision
should be individualized based on the injury severity, clinical evolution
of the patient and the presence of associated abdominal injuries [29].
Magnetic Resonance Imaging (MRI) has been described in the lit-
erature when contrast is contraindicated or CT is not available. The
pyelography allows the visualization of the ureter and the renal pelvis,
but it is limited with respect to the images for the renal parenchyma.
Decreasing renal function as reflected in creatinine increase and glo-
merular filtration decrease can lead us to suspect the presence of a renal
injury. However, Dunfee et al. [29] reported that these biochemical
parameters are not usually abnormal at the beginning.
Finally, the most invasive diagnostic option is surgery, which is
necessary when there is an unstable patient. A laparotomy allows for
full exploration and makes it possible to evaluate not only the renal
parenchyma, but also the entire abdominal cavity and perform ther-
apeutic or damage control surgery as necessary. Exploratory and
therapeutic laparoscopy may be performed to stage a lesion and in
expert hands even perform a repair or nephrectomy if necessary.
However, it is not the recommended approach if the patient is hemo-
dynamically unstable [30].
3.5. Injury classification
The most commonly used scale for renal injury is that of the
American Association for the Surgery of Trauma Organ Injury Scale
(AAST-OIS), originally created in 1989 and later revised in 2009. This
scale divides kidney injury into 5 grades from I to V directly propor-
tional to the severity and trauma complexity, and is based on strict
image criteria (Table 3) [31–35].
Historically, the most frequent injuries have been grade I (28%),
followed by grade II (26%), grade III (19%), grade IV (18%), and grade
V (9%). In our review, the degree of injury was only reported in 26 out
of the 46 papers representing 38,087 of patients. The most frequent
injury was grade I (12,222; 32%), followed by grade IV (9,580; 25%),
grade III (8,362; 22%), grade II (5,964; 16%), and grade V (1,959; 5%)
(Table 4).
4. Discussion
The management of traumatic renal injuries has undergone a para-
digm shift towards non-operative management (NOM) during the last
decades. This remains the most frequent form of management for renal

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P. Petrone, et al. International Journal of Surgery 74 (2020) 13–21

Fig. 2. Blunt mechanism comparison between operative and non-operative groups Odds Ratio (95% Cl).

Table 3
Kidney injury degrees scale from the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) [33].
Degreea Type of injury Injury description

I Contusion Micro/macroscopic hematuria, normal urological studies.

Hematoma Non-expansive subcapsular hematoma without parenchymal laceration
II Hematoma Non-expansive perirenal hematoma confirmed in the renal retroperitoneum.
Laceration Cortical laceration < 1 cm deep, without urinary extravasation.
III Laceration Cortical laceration > 1 cm deep, without rupture of the collecting system or extravasation of urine.
IV Laceration Parenchymal laceration that extends through the corticomedullary junction reaching the interior of the collecting system.
Vascular Injury of a major renal artery or vein with contained hematoma.
V Laceration Kidney burst.
Vascular Injury or avulsion of the renal pedicle by devacularizing the kidney.

a
Advance one degree in bilateral injuries up to grade III.

trauma in most patients with blunt injury [44]. Several studies have
confirmed the safety of NOM in renal trauma [10] and NOM has become
the standard in most patients with renal trauma, even in those of high
grade, with a success rate of up to 80% in hemodynamically stable pa-
tients [45]. In addition, the increasingly widespread implementation of
angioembolization for the treatment of active bleeding complications has
established an intermediate step between traditional surgery and NOM
[46]. On the other hand, immediate surgical management of injuries in
patients with hemodynamic instability is widely accepted. However,
when the indication is not clear [47], Mingoli et al. [48] has reported in
their meta-analysis that NOM for renal trauma is the treatment of choice
not only for AAST grades 1 and 2, but also for higher grade blunt and
penetrating trauma. In general, the interventional approach is favored in
patients who present with high grade renal injury and who are hemo-
dynamically stable. The factors that will determine the choice of man-
agement are the patient's stability, the grade of renal injury and the
presence of associated injuries, which is the most frequent reason for
performing a surgical renal exploration [49].
With an unstable patient, once the decision to perform a surgical ap-
proach has been made, it is essential to control the active bleeding and
intestinal contamination during the laparotomy. In the presence of an
isolated renal injury, a retroperitoneal approach could be performed,
while the transperitoneal approach is appropriate to allow for a complete
examination of the abdominal cavity to rule out injuries to other structures
[50]. Renal reconstruction is possible in many cases with nephrorraphy,
the most frequent technique used. In cases where tissue is unviable, a
partial nephrectomy may be necessary while a total nephrectomy should
be performed when such a repair is not possible [51]. The nephrectomy
rate during laparotomy performed for any reason in trauma is about 13%.
This is frequently performed in penetrating injuries, high grades of renal
injury, or with certain associated intra-abdominal injuries [52,53]. As is
reported by Valsangkar et al. [54], the laparoscopic option used by ex-
perienced surgeons is a valid option with good results in hemodynamically
stable patients. However, in acute cases open surgery is the recommended
route. Ultimately, angiography with selective arterial embolization in
cases of active hemorrhage is a reasonable choice and a less invasive
technique than laparotomy, with a success rate of more than 90% [55].
Caution is indicated with potentially unstable patients.
NOM is favored whenever possible and consists of rest, intravenous
hydration and sometimes prophylactic antibiotic therapy [48,56].

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P. Petrone, et al. International Journal of Surgery 74 (2020) 13–21

Table 4
Frequency of kidney injury degree based on the AAST-OIS classification.
Author and year (total of patients) I, n (%) II, n (%) III, n (%) IV, n (%) V, n (%)

Baverstock et al. [67], 2001 (227) 148 (0.38) 37 (0.09) 8 (0.02) 22 (0.05) 12 (0.03)
Santucci et al. [34], 2001 (2.467) 2,134 (5.55) 87 (0.22) 119 (0.30) 99 (0.25) 28 (0.07)
Saidi et al. [4], 2004 (105) 26 (0.06) 25 (0.06) 17 (0.04) 28 (0.07) 9 (0.02)
Rambeaud et al. [15], 2005 (45) 10 (0.02) 9 (0.02) 10 (0.02) 13 (0.03) 3 (0.007)
Kuan et al. [8], 2006 (8,465) 4,663 (12.13) 1,540 (4.00) 1,031 (2.68) 832 (2.16) 413 (1.07)
Shariat et al. [36], 2007 (423) 118 (0.30) 112 (0.29) 82 (0.21) 77 (0.20) 35 (0.09)
Dunfee et al. [29], 2008 (54) 12 (0.31) 8 (0.02) 22 (0.05) 10 (0.02) 2 (0.005)
Nuss et al. [55], 2009 (52) 0 0 33 (0.08) 19 (0.04) 0 (0.0)
Tasian et al. [9], 2010 (67) N/A N/A 23 (0.05) 39 (0.10) 5 (0.01)
Aragona et al. [60], 2012 (45) N/A N/A 21 (0.05) 18 (0.04) 6 (0.01)
McGuire et al. [53], 2011 (117) N/A N/A 48 (0.12) 42 (0.10) 27 (0.07)
Buckley et al. [31], 2011 (3,580) 3,026 (7.87) 151 (0.39) 171 (0.44) 181 (0.47) 50 (0.13)
Shoobridge et al. [47], 2013 (320) 69 (0.17) 81 (0.21) 79 (0.20) 54 (0.14) 37 (0.09)
Van Der Wilden [14], 2013 (206) N/A N/A N/A 154 (0.40) 52 (0.13)
Hardee et al. [28], 2013 (126) 0 0 65 (0.16) 55 (0.14) 6 (0.01)
Patel et al. [16], 2015 (320) N/A N/A 178 (0.46) N/A N/A
McPhee et al. [68], 2015 (36) 7 (0.01) 8 (0.02) 10 (0.02) 10 (0.02) 0 (0)
Bjurlin et al. [10], 2017 (19,572) 1,750 (4.57) 3,835 (9.99) 5,482 (14.3) 7,356 (19.22) 1,147 (2.99)
Broska et al. [13], 2016 (38) 2 (0.005) 16 (0.04) 7 (0.01) 9 (0.02) 4 (0.01)
Winters et al. [65], 2016 (636) N/A N/A 477 (1.24) 159 (0.41) N/A
May et al. [57], 2016 (47) N/A N/A N/A 1 (0.002) 2 (0.005)
Hampson et al. [69], 2018 (408) N/A N/A 178 (0.46) 188 (0.48) 47 (0.12)
Burns et al. [70], 2017 (48) 24 (0.06) 10 (0.02) 2 (0.005) 9 (0.02) 3 (0.007)
Terrier et al. [17], 2017 (395) 233 (0.60) 45 (0.11) 63 (0.16) 36 (0.09) 10 (0.02)
Keihani et al. [59], 2018 (431) N/A N/A 236 (0.61) 142 (0.36) 53 (0.13)
Joseph et al. [58], 2018 (36) N/A N/A N/A 27 (0.07) 8 (0.02)
Total: 38,087 12,222 (32) 5,964 (16) 8,362 (22) 9,580 (25) 1,959 (5)

N/A: Not Available.

Historically, all grades I and II injuries have been treated conservatively.
The management of grade III injury has been controversial, although
recent studies have shown that NOM is the management of choice [57].
In grades IV and V surgery is often indicated due to other associated
concomitant injuries [58–60]. Conservative management requires con-
tinuous evaluation for therapeutic success. The failure of NOM is around
2.7% in the first 24 h and can be predicted based on the degree, me-
chanism of injury and the presence of associated injuries [10,52].
Forty-one of the papers analyzed reported on the therapeutic man-
agement of patients. Of the 43,949 patients reported on, 36,403
(82.8%) of them were treated with NOM, 7,546 (17.2%) underwent an
interventional procedure which was either surgical or angioemboliza-
tion (Table 5). Out of the 41, 13 papers with 24,219 patients described
the type of treatment received based on the renal injury grade ac-
cording to the AAST scale; patients with grade IV injury had the highest
rate of intervention (1,388; 5.7%), followed by grade V (945; 3.9%),
grade III (752; 3.1%), grade II (309; 1.3%), and grade I (118; 0.5%).
5. Morbidity
After renal trauma, a wide range of complications can interfere with
a patient's life. These can be classified as early and late complications.
Early complications occur in the first month after trauma and consist of
bleeding, abscesses, hypertension, infections, and fistulae [61]. Hy-
pertension caused by renal trauma is rare and is estimated around less
than 5% [62]. Medical management is usually enough but in recidivant
hypertension, interventionist treatment may be needed [63]. Late
complications are defined as occurring after the first postoperative
month. Hydronephrosis, renal lithiasis, chronic pyelonephritis, hydro-
nephrosis, pseudoaneurysms and arteriovenous fistulae are possible
with treatment needing to be individualized in each case [61].
6. Mortality
Twenty one series with a total of 31,689 patients included the
mortality rate. Mortality rate with exact binomial confidence intervals
was presented in Fig. 3. It is important to note that amongst trauma
patients the mortality rate attributable to solely renal injury is low and
is usually due to the large degree of associated injuries. Several series
[13,14,36–38,40,42,65–69] make a distinction of mortality attributable
to renal injury to total mortality, as is the case of Bergqvist et al. [42]
who reported a total mortality of 6.5%, and a renal injury specific
mortality rate of 1.7%. Eleven of the studies reviewed distinguish this
mortality subgroup from renal etiology that accounts for only 0.6% of
patients. The analyzed articles considered bad prognostic factors to be
hemodynamic instability, advanced age, comorbidities of the patient, as
well as the number and type of associated injuries.
Several studies excluded deaths in the first hours before surgery,
which could explain the variability among published mortality. In the
same way that the AAST scale can predict the need for surgery or
complications, it is also possible to predict the probability of death
based on the degree of kidney injury [69]. Other series
[10,13,14,24,37,40,43,68] compared mortality in patients treated with
NOM versus those undergoing surgery. Mortality in patients who re-
ceived NOM treatment was 5.5% while those treated with an inter-
ventional approach had a mortality rate of up to 13.4%. Van der Wilden
[14] establishes four independent predictors of mortality and hospital
stay in patients with renal trauma undergoing surgery, namely the
presence of intraperitoneal blood, active vascular extravasation on CT
scan, ISS of 25 or greater, and the presence of associated injuries. Late
mortality was due to the development of sepsis and multi-organ failure
unrelated to renal etiology [70].
This study has limitations. Although the authors have performed the
Newcastle-Ottawa Quality Assessment Scale for both case-control stu-
dies and cohort studies, the risk of bias might be present at study and
outcome levels. Similarly, incomplete retrieval of identified research
could inadvertently be performed at the review level as well.
7. Conclusions
When a renal injury is suspected, meticulous clinical and radi-
ological evaluation are necessary to perform an adequate staging of the
injury and to identify other possible associated injuries. In addition, the
presence or absence of hemodynamic stability is of vital importance as

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P. Petrone, et al. International Journal of Surgery 74 (2020) 13–21

Table 5
Type of kidney injury treatment.
Author and year (total of patients) Invasive managementa, n (%) Non-operative management, n (%)

Nation et al. [37], 1963 (258) 23 (0.05) 235 (0.05)

Rohner et al. [38], 1971 (61) 60 (0.13) 1 (0.002)
Lang et al. [39], 1971 (74) 3 (0.006) 71 (0.16)
Del Villar et al. [24], 1972 (100) 22 (0.04) 78 (0.17)
Cass et al. [40], 1973 (54) 30 (0.06) 24 (0.05)
Bogash et al. [41], 1974 (65) 12 (0.02) 53 (0.12)
Bergqvist et al. [42], 1983 (417) 22 (0.04) 395 (0.89)
Cass et al. [43], 1985 (513) 103 (0.23) 410 (0.92)
Presti et al. [2], 1989 (18) 11 (0.02) 7 (0.01)
Nash et al. [50], 1995 (2521) 195 (0.44) 2,326 (5.27)
Baverstock et al. [67], 2001 (227) 27 (0.06) 200 (0.45)
Santucci et al. [34], 2001 (2,467) 260 (0.58) 2,207 (5.005)
Dobrowolski et al. [3], 2002 (887) 234 (0.53) 653 (1.48)
Saidi et al. [4], 2004 (105) 7 (0.01) 98 (0.22)
Kansas et al. [64], 2004 (93) 93 (0.21) 0 (0.0)
Rambeaud et al. [15], 2005 (45) 6 (0.01) 39 (0.08)
Habrat et al. [6], 2005 (324) 110 (0.24) 214 (0.48)
Kuan et al. [8], 2006 (8.465) 1,777 (4.03) 6,688 (15.16)
Shariat et al. [36], 2007 (423) 90 (0.20) 334 (0.75)
Nuss et al. [55], 2009 (52) 9 (0.02) 43 (0.09)
García et al. [12], 2009 (106) 74 (0.16) 32 (0.07)
Tasian et al. [9], 2010 (67) 44 (0.09) 23 (0.05)
Aragona et al. [60], 2012 (45) 45 (0.10) 0 (0)
McGuire et al. [53], 2011 (117) 27 (0.06) 90 (0.20)
Van Der Vlies [5], 2012 (186) 6 (0.01) 180 (0.40)
Buckley et al. [31], 2011 (3,580) 215 (0.48) 3,365 (7.63)
Sugihara et al. [7], 2012 (320) 54 (0.12) 266 (0.60)
Shoobridge et al. [47], 2013 (320) 33 (0.07) 287 (0.65)
Figler et al. [35], 2013 (84) 14 (0.03) 70 (0.15)
Van Der Wilden [14], 2013 (206) 52 (0.11) 154 (0.34)
Hardee et al. [28], 2013 (126) 12 (0.02) 114 (0.25)
Patel et al. [16], 2015 (320) 59 (0.13) 261 (0.59)
McPhee et al. [68], 2015 (36) 3 (0.06) 33 (0.07)
Bjurlin et al. [10], 2017 (19,572) 3,243 (7.35) 16,329 (37.03)
Broska et al. [13], 2016 (38) 14 (0.03) 24 (0.05)
Winters et al. [65], 2016 (636) 111 (0.25) 525 (1.19)
Hampson et al. [69], 2018 (408) 289 (0.65) 119 (0.26)
Burns et al. [70], 2017 (48) 6 (0.01) 42 (0.09)
Keihani et al. [59], 2018 (431) 131 (0.29) 300 (0.68)
Phan et al. [66], 2018 (97) 13 (0.02) 84 (0.19)
Joseph et al. [58], 2018 (36) 7 (0.01) 29 (0.06)
Total: 43,949 7,546 (17.2) 36,403 (82.8)

a
Both percutaneous drainage and angioembolization, were also included within invasive management.

Fig. 3. Mortality rate and exact binomial 95% Cl.

this helps determine management. Renal injury NOM has become the unnecessary iatrogenic nephrectomies and potential improvement in a
standard in renal trauma management with good results in morbidity patient's quality of life. When an invasive treatment is necessary, an-
and mortality. This has resulted in a decrease in the number of gioembolization for active bleeding or nephrorrhaphy is usually

19
P. Petrone, et al. International Journal of Surgery 74 (2020) 13–21

sufficient. Traumatic renal injuries represent an important challenge in [4] A. Saidi, F. Bocqueraz, J.L. Descotes, P. Cadi, N. Terrier, B. Boillot, J.J. Rambeaud,
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