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
- The Trauma Professional’s Blog — AAST Revises Renal Injury Grading
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.
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