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Background: Little data or consensus exists on the follow-up management of pediatric renal trauma patients. Our objective was to review our renal trauma experience in order to create a follow-up plan for pediatric renal trauma patients.
Methods: The records of 24 pediatric patients with the diagnosis of renal trauma between the years 2009-2012 were reviewed. Demographics, age, grade of injury, mechanism of injury, presence of concurrent injuries, presentation with gross vs microscopic hematuria, need for surgical intervention (ureteral stenting or angio-embolization), and follow-up urinalyses and ultrasound data were collected. All renal injuries were staged by CT with delayed IV contrast films. Criteria for ureteral stenting included persistent urinary extravasation on follow-up imaging in the setting of symptoms (worsening pain or fever). Criteria for angio-embolization included inadequate response to blood transfusion and hemodynamic instability. All patients had ultrasound imaging at 1 month post-injury. Patients with persistent perinephric hematoma on ultrasound had a repeat ultrasound at q3month intervals until resolution. Urinalyses were performed at follow-up visits.
Results: Twenty-four patients (ages 6 wks - 17yrs, median age = 15 yrs) with the diagnosis of renal trauma were identified. Three were excluded due to loss of follow-up. Of the 21 patients included in this study, 2 had grade 1 renal lacerations (10%), 4 grade 2 (19%), 8 grade 3 (38%), 6 grade 4 (29%), and 1 grade 5 (5%) . Twenty renal lacerations were due to blunt injury and 1 to penetrating injury. Concurrent injuries were present in 13/21 patients (62%). All patients with grade 4 and 5 injuries presented with gross hematuria. Thirty six percent of patients with grade 1-3 injuries had a negative urinalysis, without microscopic hematuria. Of the patients with grade 4 and 5 injuries, 4/7 required intervention (57%), with 2 requiring stent placement and 2 requiring angio-embolization. No grade 1-3 injuries required intervention. Of the 14 patients with grades 1-3 injuries, 11 (79%) had no evidence of perinephric hematoma on ultrasound imaging at 1 month. The remaining 3 patients had resolution at 3 months, all of which were grade 3 injuries. All patients with grade 1-2 injuries had normal ultrasound findings at 1 month. Of the 7 patients with grade 4-5 injuries, 6 (86%) had persistent perinephric hematoma at 1 month, 5 of which resolved by 3 months. One patient had a persistent perinephric hematoma until 9 month follow-up. All microscopic hematuria resolved prior to or at the time of resolution of ultrasound findings.
Conclusions: Consistent with previous studies, none of our patients required surgical exploration due to kidney injury, although a significant number of grade 4-5 injuries (57%) required stenting or angio-embolization. We propose a follow-up plan for pediatric renal trauma patients which includes a 1-month follow-up ultrasound and urinalysis for patients with grade 3 injuries and a 3-month follow-up ultrasound and urinalysis for patients with grade 4-5 injuries. Considering there were no grade 1-2 injury patients with abnormalities on 1 mo follow-up ultrasound, we do not find it necessary to re-image these patients.