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A Data-Driven Approach to Pediatric Renal Trauma
Liza M. Aguiar, MD, Katherine L. Rotker, MD, Pamela I. Ellsworth, MD, Jeremy T. Aidlen, MD, Anthony A. Caldamone, MD.
Brown University, Providence, RI, USA.
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.
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