Kidney injury  
History

- mechanism of injury

* blunt injury: extent of deceleration involved in high-velocity impact trauma

* penetrating injury: stab wound and gunshot

- Gross hematuria

Physical examination

- flank hematoma

- abdominal or flank tenderness

-associated injury: rib fractures, spinal fracture

investigation

Radiography

indication

- all penetrating trauma patients with likelihood of renal injury

- all blunt trauma with significant acceleration/deceleration mechanism of injury

- all blunt trauma with gross hematuria

- all blunt trauma with microscopic hematuria with shock (SBP < 90 mmHg)

- all pediatric patients with microscopic hematuria (> 5 RBCs/HPF)

***blunt trauma in esp. area: upper quadrant abdomen, rib 11th, 12th fracture, thoracoabdomen

 

radiography

- CT scan: gold standard

- IVP

- MRI

- angiography

- USG

- one-shot IVP

CT scan

Advantage

Disadvantage

 

Findings on CT that raise suspicion for major injury

Intravenous pyelogram

Disadvantage

- less effective in diagnosing significant renal injury than CT

- time-consuming

- only visualizes the collecting system

MRI

Advantage

- equals CT in correctly grading blunt renal injuries and particularly in detecting the presence and size of perirenal hematomas

Disadvantage

- time-consuming

- not available

Angiography - in penetrating injuries: angiography is the second study of choice behind CT because reliably it can stage significant injury and offers the possibility of embolization
USG - lack efficacy in trauma

One-shot IVP

(in operative room)

- intravenous injection of contrast media (2 mg/kg) then plain abdominal X-ray 10 minutes after that

 

indication

- when unstable vital signs that cannot CT scan

 

Advantage

- setting of an un expected retroperitoneal hematoma and may help to determine if the kidneys are injured and how well they function

   
Grades

Grading

Management

- Non-opearative management

- Opeative management

overview

Non-operative management

- hemodynamically stable well-stage patient

- 98% of blunt renal injuries

- Grade IV and V injuries more often require surgical exploration, but even high-grade injuries can be managed without renal operation if carefully staged and selected

 

- admit

- strict bedrest is mandatory until gross hematuria resolves

- observe closely, monitor vital sign and serial Hct

- antibiotics

- follow up imaging (48-72 hr)

* immediate imaging if fever, BP drop, Hct drop

- Once gross hematuria clears, ambulation is allowed

* recurrent gross hematuria: bed rest is reinstated

- beware rebleeding especially the first 2-3 wk

- Bleeding persist or delayed: angiography with embolization

- Urinary extravasation persists: placement of an internal ureteral stent

Operative management

- renal reconstruction

- nephrectomy

Absolute indication

- Hemodynamic instability with shock

- expanding/pulsatile renal hematoma (usually indicating renal artery avulsion)

- suspected renal pedicle avulsion (grade V)

- ureteropelvic junction disruption

complication

- Persistent urinary extravasation

* internal ureteral stent

- urinoma

* percutaneous drainage

- perinephric abscess

* antibiotics and drainage

- Delay renal bleeding

* embolization

- Hypertension: from renal infarction or ischemia induced RASS or page kidney or endothelial fragment induced clot then induced vasoconstriction (vascular hypertension)

* nephrectomy

- Arteriovenous fistula

- retroperitoneal hematoma