Renal Trauma

Background
 Renal trauma occurs in approximately 1-

5% of all trauma cases  The Kidney is the most commonly injured genitourinary and abdominal organ  Male to Female ratio 3:1  Renal trauma can be acutely lifethreatening, but the majority of renal injuries are mild and can be managed conservatively

Mechanism of the injury

Blunt

Penetrating

Blunt Trauma
 Secondary to motor vehicle accidents, falls,

vehicle-associated pedestrian accidents, contact sport and assaults  Traffic accidents are responsible for more than 50% of blunt renal injuries

 Renal laceration and renal vascular

injuries make up only 10-15% of all blunt renal injuries  Isolated renal artery injury following blunt abdominal trauma is extremely rare and make about 0.1% of all trauma patients  Renal artery occlusion is associated with rapid deceleration injuries.

Penetrating Trauma
 Gunshot and stab wounds represent the

most common cause of this type of trauma  Penetrating injuries tend to be more severe and less predictable than blunt ones  Gunshot usually associated with multiple organs injuries

AAST Classification

Grade I
 Contusion or

nonexpanding subcapsular hematoma, no laceration.

Grade II

 Non expanding

perirenal Hematoma  Cortical laceration < 1 cm deep without extravasation

Grade III
 Cortical laceration >

1cm without urinary extravasation

Grade IV
 Laceration: through

corticomedullary junction into collecting system Or  Vascular: Segmental renal artery or vein injury with contained hematoma or partial vessel laceration or

Grade V
 Laceration :

shattered kidney Or  Vascular : Renal pedicle avulsion

AAST Classification
Grade
I II III

Description of injury
Contusion or nonexpanding subcapsular hematoma, no laceration. Non expanding perirenal Hematoma Cortical laceration < 1 cm deep without extravasation Cortical laceration > 1cm without urinary extravasation Laceration: through corticomedullary junction into collecting system Or Vascular: Segmental renal artery or vein injury with contained hematoma or partial vessel laceration or vessel thrombosis Laceration : shattered kidney Or

IV

V

Diagnosis

History
 A direct history is obtained from

conscious patients witnesses and emergency personnel can provide valuable information about unconscious or seriously injured patients  Pre-existing renal abnormality makes renal injury more likely following trauma.  Trauma patients with Horseshoe kidney are at risk of losing all functioning renal tissue

Physical Examination
 Vital signs should be recorded

throughout diagnostic evaluation  Hemodynamic stability is the primary criterion for the management of all renal injuries  In stab wounds, the extent of entrance wound will not accurately reflect the depth of the penetration

 The following findings on physical examination

could indicate possible renal involvement:

• haematuria • flank pain

• abdominal distension

• abdominal tenderness • flank ecchymoses • flank abrasions
• abdominal mass

• fractured ribs

Laboratory Evaluation
 The trauma patient is evaluated by a

series of laboratory tests, the most important tests for evaluating renal trauma are:

• Urinalysis • Hematocrit
• Baseline Creatinine

Urinalysis
 The basic test in the evaluation of

patient with suspected renal trauma  Haematuria is the first indicator of renal injury  Neither sensitive nor specific enough to differentiate minor and major injuries  Disruption of the UPJ , renal pedicle injuries or arterial thrombosis may occur without Haematuria  9% of proven stab wound Renal injury

Hematocrit
 Initial Hematocrit associated with vital

signs indicates the need for emergency resuscitation  The decrease in Hematocrit and requirement for blood transfusion are indirect sign of the rate of blood loss

Creatinine
 An increased Creatinine reflects usually

preexisting renal pathology

Imaging
 There is mounting evidence that

following blunt trauma, some patients do not require radiographic evaluation:  Patient with microscopic haematuria and no shock after a blunt trauma have a low likelihood of developing renal injury

 Indications for imaging are:

1. Gross haematuria
2. Microscopic haematuria and shock 3. presence of major associated injuries 4. rapid deceleration injury 5. penetrating trauma with kidney

involvement suspecting

Ultrasosgraphy (US)
 popular, quick, non-invasive, low-cost

without exposure to radiation  Technical difficulty in multi-traumatic patient  Results highly depends on the operator  Can detect laceration but cannot evaluate the depth nor extent  Cannot give functional information

 Difficulty in differentiating shattered

kidney from congenitally absent kidney  More sensitive than IVP in minor blunt trauma  Decreased sensitivity when the severity of the injury increases

Standard Intravenous Pyelography (IVP)
 Was the preferred imaging method

before the CT  Presence or absence of one or the two kidneys  Defines the parenchyma  Outlines the collecting system  The most significant finding on the IVP are : nonfunctional and extravasation  Sensitivity is >92% for all degrees of severity

One-Shot Intraoperative Intravenous Pyelography (One-Shot IVP)
 Unstable patients who are unstable to

undergo CT  The technique consists of a bolus intravenous injection of 2mL/kg of radiographic contrast followed by a single plain film taken after 10 minutes  Important information for decision making  Studies showed not that good sensitivity in penetrating trauma

Computed Tomography (CT)
 Gold Standard for stable patients

 May not be available, time consuming,

high cost  Sensitivity 95.6%  Lack of contrast enhancement of the injured kidney is a hallmark of renal pedicle injury

Magnetic Resonance Imaging (MRI)
 MRI can replace CT when:

1. CT is not available
2. Iodine allergy 3. Ct findings are equivocal

Angiography
 The most common indication for

arteriography is non-visualization of a kidney on IVP after major blunt renal trauma when a CT is not available

Common causes for non-visualization

are:

 

Total avulsion of the renal vessels (usually presents with life-threatening bleeding) Renal artery thrombosis Severe contusion causing major vascular spasm.

Treatment

Approaching Unstable Trauma (penetrating or blunt)
Suspected adult renal trauma Unstable Emergency laparotomy One-shot IVP Abnormal IVP Retroperitoneal hematoma Stabl e Normal IVP

Renal Exploration

Observation

Pulsatile or expanding

Approaching Stable Blunt Trauma
Suspected adult blunt renal trauma Stable Gross Haematuria Renal Imaging Grade 3-4 Observatio n Bed rest HCT Antibiotics Rapid declaratio n injury or major associated injuries Microscopi c Haematuri a

Grade 5
Associated injuries require laparotomy

Grad e 1-2

Renal exploration

Observation

Approaching Stable Penetrating Trauma
Suspected Adult Penetrating Renal Trauma

Stable

Renal Imaging

Grade 3 Observation Bed Rest HCT antibiotics

Grade 4-5

Grade 1-2

Associated injuries requiring laparotomy

Renal Exploration

Observation

Complications
 Early complications : Delayed complications :  Bleeding  Infections  Bleeding  Peri-nephric abscess  Hydronephrosis  Urinary fistula  Calculus  Hypertension (acute Hypertension chronic)  Chronic pyelonephritis  Urinoma (  Arteriovenous fistula extravasation )  Pseudoaneurysms

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