Discuss the management of renal injuries.

Renal Injury
1. Introduction
2. Classification
3. Mechanisms
4. Grading
5. Clinical features
6. Management
1) Initial resuscitation
2) Haemodynamically unstable patient
3) Haemodynamically stable patient
4) Imaging
5) Treatment
7. Complications
8. Future & controversary
9. Conclusion
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Introduction
In current era, trauma is the leading cause of death for people between ages 1 and 40 years.
Nearly 10% of injuries seen in the ED involve the urinary tract. 1.5-3% of trauma patients have renal
injuries. Injury do not select the organ and so examinations of the whole patient to rule out other
composite injuries that may need to more urgent attention is crucial for all physicians.
In Myanmar, renal injuries are the 2nd most common injuries in the urinary tract after
urethral injuries.

Classification
Classification is very important because it predict the likely need for surgical exploration to
control bleeding. It can be classified as (1) Blunt injury and (2) Penetrating injury.
95% of blunt injuries can be managed conservatively.
50% of stab injuries and 75% of GSW need surgical exploration.
Causes
1. Blunt injury
1) Direct blow to the kidney
2) Rapid acceleration or deceleration (Rapid deceleration frequently causes renal
pedicle injury such as RA or RV tear and PUJ disruption because renal pedicle is the
site of attachment of the kidney to the other fixed retroperitoneal organs.
Commonest cause is RTA. Seemingly trivial injuries of fall from ladder, direct fall on
the flank and sports injury can lead to significant renal injury.)
3) Combination of above
2. Penetrating injury
1) Stab wound
2) GSW (wound profile of low velocity GSW is similar to that of a stab wound)

Mechanisms
The kidneys are retroperitoneal organs surrounded by perirenal fat, vertebral column and
spinal muscles, lower ribs and abdominal contents. So, it is relatively protected from injury and
cosiderable amount of force is needed to injure them. Associated injuries are therefore common.
The right kidney is more commonly injure than the left kidney because of its lower position.
Pathologic kidneys such as hydronephrosis and tumour readily injure from mild trauma.
In children, kidney is more prone to injury because of relatively greater size of kidney,
smaller protective muscle mass, less cushion of perirenal fat and more pliable rib cage.

Staging
Renal injury can be staged according to AAST organ injury severity scale using CT. Higher
scales are associated with poor outcomes.
Grade I – Contusion or subcapsular haematoma with no parenchymal laceration
Grade II – <1 cm deep parenchymal laceration of cortex (No extravasation– Collecting system intact)
Grade III – >1 cm deep parenchymal laceration of cortex (No extravasation– Collecting system intact)
Grade IV – Parenchymal laceration involving cortex, medulla and collecting system
(Or RA/RV injury with contained haemorrhage)
Grade V – Completely shattered kidney
(Or avulsion of renal hilum)
Renal injury can also be differentiated into two types according to the severity; minor and
major injury.
Minor injury – Subcapsular haematoma, cortical tear, corticocalyceal tear
Major injury – Lacerated kidney, polar avulsion, pedicular injury
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Clinical features
Haematuria is the commonest symptom but it may be absent or delayed in about in 30% of
cases. Loin pain, flank ecchymosis, tenderness and mass can be present. Hypovolaemic shock may
be present in severe injury with large retroperitoneal haematoma. Abdominal pain, rigidity,
guarding and presence of intraperitoneal free fluid strongly indicate associated intraperitoneal
injury.

Management
Initial resuscitation
The resuscitation is initiated in the field by paramedic team. Goals of resuscitation are:
1. Restoration of cardiac, pulmonary and neurological function
2. Diagnosis of life threatening conditions
3. Prevention of complications from multisystem injuries.
Initial resuscitation process can be divided into 3 phases.
I. Primary survey (ABC, Imaging, Urinalysis)
II. Secondary survey (H/O, PE, Selective Skeletal X-Rays)
III. Definitive survey (Focus on specific organ/ Genitourinary injury are usually recognized during
this survey)

Haemodynamically stable patient

1. History (Nature of trauma)
2. PE (BP, PR, RR, Location of entrance & Exit wounds, flank Bruise, Rib fracture)
3. Urinalysis (Crucial for determination of likelihood of renal injury)
4. FBC, Serum chemistry profile
5. Indications for Renal imaging
1) Macroscopic haematuria
2) Microscopic haematuria in hypotensive patient
3) Child with any haematuria
4) Penetrating wound
5) Rapid acceleration or deceleration injury
USG
1) To confirm 2 kidneys and perinal haematoma
2) To identify blood flow in the renal vessels (Power Doppler)
KUB X-Rays
1) # 12th rib
2) # of transverse process
3) soft tissue shadow in renal area
4) displacement of adjacent bowel gas shadow
IVU
1) Extravasation of contrast
(Amount of extravasation does not correlate with degree of injury)
2) Real value is to make sure that opposite non-injured kidney is present and normal.
CECT
1) To grade injury
2) Depth of parenchymal laceration
3) Parenchymal enhancement (lack of enhancement suggest renal artery injury)
4) Urinary extravasation (Medial extravasation of contrast suggest disruption of PUJ or renal
pelvic)
5) Retroperitoneal haematoma (Haematoma medial to kidney suggest a vascular injury)
6) Adjacent organ injury
7) Normal contralateral kidney
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Arteriography (Renal Angiogram)

1) To detect arterial injury suspected on IVU/CT
2) To localize arterial bleeding that can be controlled by embolization

Haemodynamically unstable patient

The patient may preclude standard imaging such as CT. The patient is needed to be taken
emergency operation to control bleeding. During operation, an on-table IVU is indicated if
1) a retroperitoneal haematoma is found
2) renal injury is found which is likely to require nephrectomy.
On-table IVU
A single shot abdominal X-rays taken 10 minutes after contrast administration (2ml/kg) which
can establish the presence of renal injury and normally functioning contralateral kidney.

Treatment
Conservative treatment
95% of blunt injury, 50% of stab wound and 25% of GSW can be managed conservatively.
• Microscopic haematuria
Imaging and admission are not required if SBP >90 mmHg since injury and no history of
acceleration or deceleration injury.
• Macroscopic haematuria
Admission is required for bed rest in low grade and cardiovascularly stable patient.
• High grade injury (IV and V)
It can be managed conservatively if cardiovascularly stable. But high grade injury may be
required nephrectomy to control bleeding. Current guidelines recommend reimaging for
patients with high grade injury after 2-4 days.

Interventional Radiology/ Transcatheter Arterial Embolization (TAE)

Embolization is increasingly used for all grades of renal injury.

Surgical Exploration
Surgical exploration is indicated for following conditions.
1. The patient developed shock which does not respond to resuscitation.
2. Hb decrease
3. Urinary extravasation with associated bowel or pancretic injury
(Urinary extravasation alone is not an indication for exploration. 80-90% of these conditions
will heal spontaneously)
4. Expanding perirenal haematoma
5. Pulsatile perirenal haematoma
(Expanding or pulsatile perirenal haematoma suggests a renal pedicle avulsion)

Technique
Midline incision (transperitoneal) allows exposure of the renal pedicle allowing early control
of the RA & RV and inspection of other intra-abdominal organ injury.
Lift the small bowel upwards to allow access to the retroperitoneum. Incise the peritoneum
over the aorta, above the IMA. Large perirenal haematoma may obscure the correct site for this
incision. After exposing RA & RV, the slings are passed around these vessels. Expose the kidney
by lifting the colon. Control the bleeding vessels within the kidney with 4/0 vicryl. Close any
defect in the collecting system with 4/0 vicryl. Finding of an expanding or pulsatile perirenal
haematoma at laparotomy often indicate renal pedicle injury and nephrectomy may be required
to stop further bleeding.
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Complications
Early
1. Delayed bleeding
2. Urinary extravasation & urinoma formation
(If low volume and non-infected, heal spontaneously. For large volume, DJ stent may be
inserted.)
3. Abscess formation
4. Renal AV fistula

Late
1. Hypertension
(Page kidney is the excess renin excretion which occurs following renal ischemia from renal
artery thrombosis & injury resulting hypertension.)
2. Reduced renal function

Future and controversies

Operative technique (Central vascular control)
Proponents believe that data demonstrate enhanced renal salvage when vascular control is
obtained outside the Gerota’s fascia. This technique allows controlled assessment of the nature of
the renal laceration.
Opponents believe that not all renal injuries have sufficient bleeding to warrant central control
of vessels. This technique requires some operative time and exposes the renal vessels to the
potential operative trauma.

Conclusion
Renal injury may manifest in a dramatic fashion for both the patient and urologist. The
management has evolved during the last decades with a clear transition toward a non-operative
approach. Interventional radiology and endourologic manipulation have increased the ability to
successfully treat patient without surgery. But in the setting of significant haemodynamic instability,
operative exploration remains the diagnostic and therapeutic modality of choice.

Dr. Aung Ko Htet