Kidney trauma

Reviewed and revised 22 December 2015

OVERVIEW

  • Most genitourinary injuries are not immediately life-threatening
  • Renal pedicle injury can lead to life-threatening hemorrhage and renal ischemia

ASSESSMENT

Clinically significant injuries will have at least one of:

  • Macroscopic haematuria (About 5% of renal injuries and up to 20% of renovascular injuries lack even microscopic hematuria)
  • Loin tenderness and/ or swelling
  • Haemodynamic instability

Fracture of the lower posterior ribs, lower thoracic or lumbar vertebrae may also be present

Imaging

  • CT abdomen with IV contrast is the investigation of choice (injury severity is graded I to V)
  • IVP (intravenous pyelogram) is an option if CT is unavailable or imaging needs to be carried out in the operating theatre, but is less sensitive and does not visualize non-urologic injuries
  • Renal angiography is rarely required

GRADING

American Association for Surgery of Trauma Organ Injury Scale based on:

  • haematoma size (relation to capsule, size, expanding)
  • laceration size (parenchymal depth)
  • urinary extravasation
  • cortex, medulla and collecting system involvement
  • vessel involvement
  • integrity of kidney
  • vascular status
  • whether one or both kidneys involved

Grade       Description of Injury

I                   haematuria, no parenchymal involvement, subcapsular, normal urogram

II                 non-expanding, confined to retroperitoneum, < 1cm, no urinary extravasation

III                >1cm involving renal cortex (no urinary extravasation or collecting system involvement)

IV                 cortex, medullary and collecting system or vascular involvement

V                  shattered or an avulsed kidney

MANAGEMENT

  • ATLS approach
  • Urology consult
  • Most renal injuries (Grades I to III, and most Grade IV injuries) can be managed conservatively, as they tend to heal spontaneously
  • Surgical repair is needed for urinary extravasation or if ongoing bleeding or haemodynamic instability due to renal injury
  • Alternatives to operative repair are interventional radiology to embolise bleeding vessels or to stent dissected renal arteries, and urinary extravasation may be amenable to stenting
  • Grade V injuries (avulsed kidneys) need operative intervention and often require nephrectomy

Reference and Links

LITFL

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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