Renal trauma: Difference between revisions
 
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==Background==
==Background==
[[File:Urinary system.png|thumb|'''(1) Human urinary system:''' (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra. <Br>'''Additional structures:''' (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.]]
[[File:Blausen 0592 KidneyAnatomy 01.png|thumb|Renal anatomy.]]
[[File:Blausen 0592 KidneyAnatomy 01.png|thumb|Renal anatomy.]]
[[File:PMC5265200 13244 2016 536 Fig1 HTML.png|thumb|Perinephric space with exaggerated pararenal space to show retroperitoneal structures. Perinephric bridging septa are seen between the left kidney and the adjacent renal fascia.]]
[[File:PMC5265200 13244 2016 536 Fig1 HTML.png|thumb|Perinephric space with exaggerated pararenal space to show retroperitoneal structures. Perinephric bridging septa are seen between the left kidney and the adjacent renal fascia.]]
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==Differential Diagnosis==
==Differential Diagnosis==
{{Lower GU trauma DDX}}
{{Abdominal trauma DDX}}
{{Abdominal trauma DDX}}


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===Diagnosis===
===Diagnosis===
====AAST Grading System for renal injuries====
====AAST Renal Injury Scale====
*Non-operative management<ref>Shariat, S. F., Roehrborn, C. G., Karakiewicz, P. I., Dhami, G. and Stage, K. H. (2007) ‘Evidence-Based Validation of the Predictive Value of the American Association for the Surgery of Trauma Kidney Injury Scale’, The Journal of Trauma: Injury, Infection, and Critical Care, 62(4), pp. 933–939.</ref>
{| {{table}}
**'''Grade I:''' Cortex contusion
| align="center" style="background:#f0f0f0;"|'''Grade'''
**'''Grade II:''' Cortex laceration
| align="center" style="background:#f0f0f0;"|'''Description'''
*Possible operative management
| align="center" style="background:#f0f0f0;"|'''Image'''
**'''Grade III:''' Corticomedullary junction laceration
| align="center" style="background:#f0f0f0;"|'''CT Example'''
**'''Grade IV:''' Collecting system laceration
|-
*Operative management
| '''I'''
**'''Grade V:''' Shattered kidney, thrombosis of renal artery, avulsion of hilum
||
*Contusion
**Microscopic or gross hematuria. Urological studies normal.
*Hematoma
**Subcapsular, non-expanding without parenchymal laceration.
||
[[File:Renal-trauma-grading-diagrams.jpg|140px|Grade I]]
||
[[File:Grade I.jpg|140px|Grade I]]
|-
| '''II'''
||
*Hematoma
**Non-expanding peri-renal hematoma confined to renal retroperitoneum.
*Laceration
**<1.0 cm parenchymal depth of renal cortex without urinary extravasation.
||
[[File:Renal-trauma-grading-diagrams (2).jpg|150px|Grade II]]
||
[[File:Grade II.jpg|150px|Grade II]]
|-
| '''III'''
||
*Laceration
**>1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation.
||
[[File:Renal-trauma-grading-diagrams (3).jpg|150px|Grade III]]
||
[[File:Grade III.jpg|150px|Grade III]]
|-
| '''IV'''
||
*Laceration
**Parenchymal laceration extending through renal cortex, medulla, and collecting system.
*Vascular
**Main renal artery or vein injury with contained hemorrhage.
||
[[File:Renal-trauma-grading-diagrams (4).jpg|150px|Grade IV]]
||
[[File:Grade IV.jpg|150px|Grade IV]]
|-
| '''V'''
||
*Laceration
**Completely shattered kidney.
*Vascular
**Avulsion of renal hilum that devascularises kidney.
||
[[File:Renal-trauma-grading-diagrams (5).jpg|150px|Grade V]]
||
[[File:Grade V2.jpg|130px|Grade V]]
|-
|}


==Management==
==Management==
*Based on grade of injury (above)
*Based on grade of injury (above)
*Grade I and II
**observation, vital signs monitoring, bed rest, antibiotic prophylaxis, monitor hematuria
*Prophylactic IV [[antibiotics]] for grade IV, V injuries (first generation [[cephalosporin]], [[ciprofloxacin]], or [[ampicillin]] and [[gentamicin]])
*Prophylactic IV [[antibiotics]] for grade IV, V injuries (first generation [[cephalosporin]], [[ciprofloxacin]], or [[ampicillin]] and [[gentamicin]])
*Absolute indications for operative renal exploration and intervention:
*Absolute indications for operative renal exploration and intervention:
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==See Also==
==See Also==
*[[GU Trauma]]
*[[GU Trauma]]
==External Links==


==References==
==References==

Latest revision as of 17:10, 3 May 2023

Background

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.
Renal anatomy.
Perinephric space with exaggerated pararenal space to show retroperitoneal structures. Perinephric bridging septa are seen between the left kidney and the adjacent renal fascia.
  • Approximately 10% of blunt injuries include renal trauma
  • Blunt mechanism 9x more common than penetrating[1]

Clinical Features

  • Flank pain
  • Hematuria (gross or microscopic)
  • Page kidney (late finding) - hypertension resulting from long-standing compression of from renal parenchyma by subcapsular hematoma

Differential Diagnosis

Genitourinary Trauma

Abdominal Trauma

Evaluation

Delayed-phase CT shows fluid filling the right perinephric space in a patient following blunt trauma. The kidney has been lacerated (short arrow), and urinary contrast extravasation is shown posteriorly (long arrow)

Workup

  • CT with contrast

Diagnosis

AAST Renal Injury Scale

Grade Description Image CT Example
I
  • Contusion
    • Microscopic or gross hematuria. Urological studies normal.
  • Hematoma
    • Subcapsular, non-expanding without parenchymal laceration.

Grade I

Grade I

II
  • Hematoma
    • Non-expanding peri-renal hematoma confined to renal retroperitoneum.
  • Laceration
    • <1.0 cm parenchymal depth of renal cortex without urinary extravasation.

Grade II

Grade II

III
  • Laceration
    • >1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation.

Grade III

Grade III

IV
  • Laceration
    • Parenchymal laceration extending through renal cortex, medulla, and collecting system.
  • Vascular
    • Main renal artery or vein injury with contained hemorrhage.

Grade IV

Grade IV

V
  • Laceration
    • Completely shattered kidney.
  • Vascular
    • Avulsion of renal hilum that devascularises kidney.

Grade V

Grade V

Management

  • Based on grade of injury (above)
  • Grade I and II
    • observation, vital signs monitoring, bed rest, antibiotic prophylaxis, monitor hematuria
  • Prophylactic IV antibiotics for grade IV, V injuries (first generation cephalosporin, ciprofloxacin, or ampicillin and gentamicin)
  • Absolute indications for operative renal exploration and intervention:
    • Life-threatening hemorrhage
    • Expanding, pulsatile, or non-contained retroperitoneal hematoma
    • Renal avulsion injury
  • Page kidney treatment involves ACE inhibitor and possible drainage of hematoma

Disposition

Admit

  • Penetrating renal injuries
  • Gross hematuria
  • Grade II or higher injury

Discharge

  • Microscopic hematuria and no indication for imaging
  • Isolated renal trauma with Grade I injury
    • Ensure close followup and instruct no heavy lifting

See Also

External Links

References

  1. ↑ Miller, K. S. and McAninch, J. W. (1995) ‘Radiographic Assessment of Renal Trauma’, The Journal of Urology, pp. 352–355.
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