The kidney is the most commonly injured organ in the genitourinary system and renal trauma is seen in up to 5% of all trauma cases 12, and in 10% of all abdominal trauma cases 14. Genitourinary trauma involves injury to the kidneys, ureters, bladder, andor urethra. The urological trauma guidelines were first published in 2003. Pdf contemporary management of renal trauma researchgate. A practical guide to evaluation and management article pdf available in the scientific world journal 4 suppl 1. Consider renal injury with penetrating abdominal injury see guideline for evaluation of. In mvas, renal trauma is seen after direct impact into the seatbelt or steering wheel frontal crashes or from body panel intrusion in side impact crashes 12. Delayed images should be done about 10 to 15 minutes after the initial study. The diagnosis of genitourinary trauma typically relies on patient history, physical examination, urinalysis, and imaging ct, cystoscopy, retrograde urethrogram. Measures to prevent aki include optimization of volume status and avoidance of nephrotoxic medications.
Aast kidney injury scale dr mahmoud ibrahim mekhaimar and assoc prof frank gaillard et al. Operative and nonoperative management for renal trauma. Ureteral trauma is relatively rare but due mainly to iatrogenic injuries, and in penetrating gunshot wounds both in military and civilian settings. Management of highgrade blunt renal trauma sciencecentral. This difference has been attributed to the involvement of men in highrisk activities. Clinical practice guideline acute kidney injury aki.
In general, blunt injuries are more common, accounting for up to 90%95% of renal injuries. Ct is the most informative radiologic study in renal trauma and is the examination of choice in patients suspected of having serious renal injuries or associated injuries amenable to ct evaluation. Aast kidney injury scale radiology reference article. A ccidental trauma is the leading cause of death among children and adolescents. Timothy evans, md, facep associate professor, department of emergency medicine, virginia commonwealth universitymedical college of virginia hospitals and christine murphy, md, resident iii, department of emergency medicine, virginia commonwealth universitymedical college of virginia hospitals in richmond, va. In general, hematuria 5 red blood cells per highpower field is present in over 95% of patients who sustain renal trauma, 1. Renal trauma can result from direct, blunt, penetrating and iatrogenic injury.
New methods of management supplant traditional techniques. When aki is present, prompt workup of the underlying cause should be pursued, with speci. Aragona f, pepe p, patane d, malfa p, darrigo l, pennisi m. The management of urogenital trauma aims to restore homeostasis and normal. Management of severe blunt renal trauma in adult patients. Jan 01, 2019 renal trauma may manifest in a dramatic fashion for both the patient and the clinician. We performed a retrospective study of high grade blunt renal injuries at our level i trauma center to determine the indications and success of nonoperative management nom. Collaboration between the eastern association for the surgery of trauma and the pediatric trauma society judith c. Pdf in the management of renal trauma, surgical exploration inevitably leads to nephrectomy in all but a few specialized centers. Current management of highgrade blunt renal trauma favors a nonoperative approach when possible. Management of blunt and penetrating renal trauma uptodate.
Numerous studies have found that aki is associated with an increased mortality and adverse outcomes regardless of patient characteristics and the context in which injury occurs 2, 3. Contemporary evaluation and management of renal trauma a male predominance of 3. Renal trauma may manifest in a dramatic fashion for both the patient and the clinician. Acute kidney injury aki is an abrupt and usually reversible decline in the glomerular filtration rate gfr. In the management of renal trauma, surgical exploration inevitably leads to nephrectomy in all but a few specialized centers. The englishlanguage literature about renal trauma was identi. Conservative management has been increasingly applied to patients with renal trauma due to the success this option has seen in handling other solid organ injuries. While nonoperative management of lowgrade blunt renal injuries is the standard of care, nonoperative management of highgrade blunt injuries and penetrating renal injuries is controversial.
It is the most commonly injured gu organ from civilian external trauma. Standard procedure for eau guidelines includes an annual assessment of newly published literature in the field to guide future updates. The lions share of renal trauma patients are managed nonoperatively with careful monitoring, reimaging when there is any deterioration, and. Renal and urogenital injuries occur in approximately 1020% of abdominal trauma in adults and children.
The optimal methods of managing injuries to the genitourinary tract have remained controversial. As our ability to image the genitourinary tract improves, and the concept of nonoperative management of solid organ injury has extended to include renal trauma. However, the absence of hematuria does not preclude significant renal injury. Intravenous loop diuretics, as a bolus or continuous infusion, can be helpful for this purpose. The evolution in the management of renal trauma has been made possible by advances in both imaging and minimally invasive techniques. Ensure that acute kidney injury is considered when an adult, child or young person presents with an illness with no clear acute component and has any of the following. Glomerular causes of acute kidney injury are the result of acute inflammation of blood vessels and glom eruli.
Renal trauma the kidney is the most frequently injured urologic organ, with 70% ot 80% being a consequence of blunt trauma. Kidney renal trauma is when a kidney is injured by an outside force. Glomerulonephritis is usually a manifestation of a systemic illness e. The diagnosis and management of renal trauma sage journals. Advances in radiographic staging, improvements in hemodynamic monitoring, and wider use of angioembolization have improved the rates of renal preservation and decreased unnecessary surgery the majority of blunt and many penetrating injuries to the kidneys no longer require open. Jan 01, 2019 in the setting of blunt renal trauma and selected instances of penetrating renal trauma, a nonoperative approach may be selected. Bladder rupture from blunt trauma is typically associated. Emergency management of renal and genitourinary trauma eb. Nonoperative management of renal injuries was begun in an attempt to avoid the high. Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy.
However, there is a debate on the management of patients with highgrade renal injury. The american association for the surgery of trauma aast renal injury scale, most recently updated in 2018, is the most widely used grading system for renal trauma. Incidence and management of penetrating renal trauma in patients with multiorgan injury. The classification includes three graded stages of aki risk, injury, and failure with two outcomes. Optimal management should take into consideration the anatomic injury, the hemodynamic. Pazooki d et al 2018 conservative management o f renal trauma renal trauma, a literature rev iew and practical clinical guideline, international journal o f current advanced research, 077. Renal trauma patients are largely managed conservatively but on occasion have to be embolised or taken to theatre for definitive surgical management, usually in the form of emergency nephrectomy. Renal and urogenital injuries occur in approximately 1020% of. Jun 29, 2018 rodrigo donalisio da silva, md urges urologists to manage blunt and penetrating renal trauma conservatively. Feb 09, 2018 posttrauma care and follow up repeat imaging is recommended for all hospitalized patients within 24 days of significant renal trauma, especially in cases of fever, flank pain, or falling hematocrit blankenship jc, gavant ml, cox ce, et al.
In the management of renal trauma, surgical exploration typically leads to nephrectomy in all but a few specialized centers. He uses the 2017 american urological association aua urotrauma guidelines to outline. All sections of the 2020 urological trauma guidelines have been fully updated. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for highgrade renal trauma hgrt.
The management of renal trauma has developed over several decades as a result of concerted single. But injuries can happen as a result of blunt trauma or penetrating trauma. Blunt renal trauma and the predictors of failure of nonoperative management. Successful nonoperative management of highgrade blunt renal. We aimed to describe the contemporary management of hgrt in the united states and also. To evaluate the current practice patterns of practitioners managing high grade renal trauma and determine perceived need for a prospective trial on the management of renal trauma. Conversely, the ribs can become the source of injury if a fracture fragment passes into the kidney. Blunt trauma damage caused by impact from an object that doesnt break the skin.
Nowadays, ct plays a major role in investigation of renal trauma and is currently the imaging modality of choice. Importance of delayed imaging for blunt renal trauma. Acute kidney injury aki is a heterogeneous disorder that is common in hospitalized patients and associated with short and longterm morbidity and mortality. Ct is important in order to characterize and grade the renal. This results in an elevation of serum blood urea nitrogen bun, creatinine, and other metabolic waste products that are normally excreted by the kidney.
Blunt renal trauma in children with previously undiagnosed preexisting renal lesions and guidelines for effective initial management of kidney injury. In children, blunt trauma is responsible for 90% of renal injuries, and the. Patient selection is the preliminary step in adopting a nonoperative management strategy to renal trauma. Renal injury is the most common organ injured in the urogenital system. Overall about 65% of genitourinary gu injuries involve the kidney. Renal trauma management has evolved during the last decades, with a distinct evolution toward a nonoperative approach. The incidence of renal trauma somewhat depends on the patient population being considered. The kidney is injured in up to 10% of patients who sustain significant abdominal trauma. Contemporary management of acute kidney trauma sciencedirect. Genitourinary trauma knowledge for medical students and. Jul 10, 2018 renal trauma management has evolved during the last decades, with a distinct evolution toward a nonoperative approach. Acute kidney injury an overview of diagnostic methods and. Algorithms summarizing the recommendations of the subcommittee are shown in fig.
In patients with blunt trauma and in certain cases of penetrating trauma. When a highgrade renal injury is suspected, contrastenhanced ct should be done to determine the grade of renal injury and identify accompanying intraabdominal trauma and complications, including retroperitoneal hemorrhage and urinary extravasation. The improvements in imaging and the use of a validated renal injury grading system has helped to. Provide guidelines for the management of renal contusions, renal fractures, renal vascular. Consider renal injury with any injury associated with hematuria see guideline for hematuria.
Eau guidelines on urological trauma european urology. Pediatric renal injuries are evaluated similarly, except that all children with blunt trauma in whom urinalysis shows 50 red blood cells rbcshighpower field require imaging. These studies highlight a need for more standardized, evidence based renal trauma management guidelines. Urotrauma guideline american urological association. An evolutionary pattern is seen in the development of diagnostic methods, while surgical and medical management of renal trauma has become much more precise for specific lesions. This guidance has been updated and replaced by nice guideline ng148. The management of renal injuries is controversial, as. Acute kidney injury aki, formerly termed acute renal failure, is characterized by a sudden deterioration in renal function.
Successful nonoperative management of highgrade blunt. Because children maintain a higher vascular tone than adults and maintain blood pressure despite high degrees of blood loss, hypotension is an insensitive sign of. In addition renal trauma management and outcomes have been demonstrated to vary by trauma level designation, with level 1 trauma centers more likely to perform conservative management, including angioembolization 5,16. Ccsap 2017 book 2 renal pulmonary critical care 8 acute kidney injury based on changes in two markers. Evidencebased recommendations for the diagnosis and management of renal trauma were made with reference to a. With current management options, the majority of hemodynamically stable patients with renal injuries can be successfully managed nonoperatively. A synthesis of prevailing thought is depicted diagrammatically in figure 2 and is summarized as follows. Although few urologic injuries are immediately lifethreatening, they do account for some of the more frequent complications of trauma.
Contemporary evaluation and management of renal trauma. The lions share of renal trauma patients are managed nonoperatively with careful monitoring, reimaging when there is any deterioration, and the use of minimally invasive procedures. The rarity of renal trauma limits its study and the strength of evidencebased guidelines. When aki is present, prompt workup of the underlying cause should be pursued, with specific attention to reversible causes. It may result in high morbidity if not properly identified and managed. Pediatric blunt renal trauma practice management guidelines. Most renal injuries 85 to 90% of cases result from blunt trauma. Epidemiology renal injuries account for 10% of abdominal trauma, and thus the demographic of affected individuals reflects that population. Your kidneys are guarded by your back muscles and rib cage. Evaluation of renal function after major renal injury.
However, it is important to note that diuretics do not improve morbidity, mortality, or renal outcomes, and should not be used to prevent or treat acute kidney injury in the absence of volume overload. Bladder injuries may be secondary to blunt or penetrating trauma. Nonoperative management was performed in patients with injury to renal artery in 9 and a branch of the renal artery in 4, with a renal lossdelayed nephrectomy rate of 99 renal artery injuries. Seen in 5% of trauma victims, it makes up 24% of traumatic abdominal solid organ. The approach to the diagnosis and management of renal trauma continues to evolve. Renal association clinical practice guidelines on acute kidney injury. In the setting of significant hemodynamic instability, operative exploration remains the diagnostic and therapeutic modality of choice. We present an overview of renal trauma as illustrated by three interesting cases of blunt renal trauma who presented in quick succession of each other to the emergency department. The conservative management of blunt renal trauma was first proposed in the. Genitourinary trauma, management of practice management. Suspected renal trauma results from reported mechanism of injury and physical examination. The priorities of renal trauma management are on descending order avoiding mortality by bleeding control, nephron sparing and avoiding complications.
1248 1021 869 359 1049 306 490 367 37 917 1231 529 1299 564 548 1132 460 949 929 154 545 161 1011 625 490 683 1126 913 1395 247 1075 1288 820 1260 568 17 98