1. George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital
Renal Trauma
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, MO

2. Renal Trauma Trauma is most common cause of death in children
Injuries to the kidneys account for 60% of genitourinary injuries
90% blunt trauma
Usually do not require operation
10-20% penetrating trauma
More often require operation
Deceleration/flexion injuries
Produce renal arterial or venous injuries

3. Renal Trauma
Due to their size and location, kidneys are susceptible to injury from blunt trauma
Children are more susceptible than adults to major renal injury
Less perirenal fat
Weaker abdominal musculature
Less well-ossified thoracic cage
Kidneys with congenital abnormalities are at increased risk of injury
Pediatric evaluation and treatment guidelines not clearly defined for children

4. Renal Trauma Standard Imaging Modality – (U.S.)
CT scan often performed in trauma w/u
CT scan recommended in patients with hematuria
Ultrasound may be used to screen hemodynamically unstable patients
FAST 95% specificity, but 33-89% sensitivity

5. Renal Trauma Management goal: renal salvage
Indications for immediate exploration
Hemodynamic instability
Penetrating injury – unstable patient
Associated non-renal injuries
Nephrectomy required in less than 10% of cases
Isolated penetrating renal injury in stable patient can be managed conservatively
Aggressive radiologic, laboratory and clinical efforts important in managing patients w/o operation

6. American Association for the Surgery of Trauma Injury Scale
Grade
Injury
Description of Injury I
Contusion
microscopic or gross hematuria
urologic studies normal
Hematoma
subcapsular, nonexpanding
no parenchymal laceration II
nonexpanding perirenal hematoma confined to renal retroperitoneum
Laceration
< 1.0-cm parenchymal depth of renal cortex
no urinary extravasation
III
> 1.0-cm parenchymal depth of renal cortex
no collecting system rupture or extravasation IV
parenchymal laceration extending through renal cortex, medulla, and collecting system
Vascular
main renal artery or vein injury with contained hemorrhage V
completely shattered kidney
avulsion of renal hilum that devascularizes kidney

7. Renal Trauma Stable grade I-III injuries Severe grade IV-V
Managed non-operatively
Severe grade IV-V
Require careful selection based on
hemodynamic stability
mechanism
associated non-renal injuries
Stable patients may need monitoring in ICU setting

8. Renal Trauma Management Inconclusive data Antibiotics Bedrest
Likely only needed when stent placed
Bedrest
Variable practice: bedrest for 5-7 days, or until hematuria clears, or once physically able
No consensus

9. Renal Trauma Management Ureteral stent indications
80% of grade IV and V collecting system injuries heal without intervention
If collecting system extravasation does not resolve within two weeks, stenting is then considered
Symptomatic urinomas may require stenting
Lack of contrast in ipsilateral ureter may indicate significant injury, necessitating stent

10. Renal Trauma Complications Follow-up imaging Hypertension
Estimated incidence: %
Follow-up imaging
Little data to support its use

11. J Pediatr Surg 45: , 2010

12. Children’s Mercy 1995 - 2007 All patients with blunt renal trauma
Mean age 11 yrs
MVC - 44%
Falls %
Sports - 22%
Grade I - 26%
Grade II - 23%
Grade III - 35%
Grade IV - 13%
Grade V - 3%
J Pediatr Surg 45: , 2010

13. Children’s Mercy Isolated renal injury - (44%)
Bed rest ± 1.9 d (mean)
Hospital ± 3.1 d (mean)
Blood tx – 15 pts
Mean vol – 700 c
Op – 6 pts – None for renal injury
No tx in isolated renal injury
No tx Grade IV or V injury
Renal salvage – 99.1%
One nephrectomy in pt w/ESRD
HTN – 3 pts – 1 resolved
Urinoma – 1 pt – resolved w/drainage
J Pediatr Surg 45: , 2010

14. Renal Trauma
CMH is currently participating in multi-institutional, prospective, randomized trial with long-term follow-up
Patients allowed out of bed when physically able
Daily UA while in hospital
Once discharged, weekly UA until hematuria is cleared
Discharged when patients meet general discharge criteria
3 year follow-up for hypertension

15. References
Fraser, JD, Aguayo P, Ostlie DJ, et al: Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int (2009) 25:
Holcomb GW III, Murphy JP. Ashcraft’s Pediatric Surgery. 5th ed. Philadelphia, PA: Saunders An Imprint of Elsevier, 2010.
Nerli RB, Metgud T, Patil S, et al: Severe renal injuries in children following blunt abdominal trauma: selective management and outcome. Pediatr Surg Int (2011) 27:
Suson KD, Gupta AD, Wang MH. Bloody urine after minor trauma in a child: isolated renal injury versus congenital anomaly? J Pediatr. (2011) 159:870.

16. QUESTIONS www.cmhclinicaltrials.com
Finally, until a more efficacious, more cost effective and more efficient (with regard to health care providers and families) antibiotic regimen is identified, this study supports the use of single day dosing of ceftriaxone/metronidazole as the initial treatment regimen in children with perforated appendicitis.