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

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