George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Renal Trauma George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO

Renal Trauma Trauma is most common cause of death in children Injuries to the kidneys account for 60% of genitourinary injuries 90% blunt trauma Usually do not require operation 10-20% penetrating trauma More often require operation Deceleration/flexion injuries Produce renal arterial or venous injuries

Renal Trauma Due to their size and location, kidneys are susceptible to injury from blunt trauma Children are more susceptible than adults to major renal injury Less perirenal fat Weaker abdominal musculature Less well-ossified thoracic cage Kidneys with congenital abnormalities are at increased risk of injury Pediatric evaluation and treatment guidelines not clearly defined for children

Renal Trauma Standard Imaging Modality – (U.S.) CT scan often performed in trauma w/u CT scan recommended in patients with hematuria Ultrasound may be used to screen hemodynamically unstable patients FAST 95% specificity, but 33-89% sensitivity

Renal Trauma Management goal: renal salvage Indications for immediate exploration Hemodynamic instability Penetrating injury – unstable patient Associated non-renal injuries Nephrectomy required in less than 10% of cases Isolated penetrating renal injury in stable patient can be managed conservatively Aggressive radiologic, laboratory and clinical efforts important in managing patients w/o operation

American Association for the Surgery of Trauma Injury Scale Grade Injury Description of Injury I Contusion microscopic or gross hematuria urologic studies normal Hematoma subcapsular, nonexpanding no parenchymal laceration II nonexpanding perirenal hematoma confined to renal retroperitoneum Laceration < 1.0-cm parenchymal depth of renal cortex no urinary extravasation III > 1.0-cm parenchymal depth of renal cortex no collecting system rupture or extravasation IV parenchymal laceration extending through renal cortex, medulla, and collecting system Vascular main renal artery or vein injury with contained hemorrhage V completely shattered kidney avulsion of renal hilum that devascularizes kidney

Renal Trauma Stable grade I-III injuries Severe grade IV-V Managed non-operatively Severe grade IV-V Require careful selection based on hemodynamic stability mechanism associated non-renal injuries Stable patients may need monitoring in ICU setting

Renal Trauma Management Inconclusive data Antibiotics Bedrest Likely only needed when stent placed Bedrest Variable practice: bedrest for 5-7 days, or until hematuria clears, or once physically able No consensus

Renal Trauma Management Ureteral stent indications 80% of grade IV and V collecting system injuries heal without intervention If collecting system extravasation does not resolve within two weeks, stenting is then considered Symptomatic urinomas may require stenting Lack of contrast in ipsilateral ureter may indicate significant injury, necessitating stent

Renal Trauma Complications Follow-up imaging Hypertension Estimated incidence: 0 - 7.5% Follow-up imaging Little data to support its use

J Pediatr Surg 45:1311-1314, 2010

Children’s Mercy 1995 - 2007 All patients with blunt renal trauma Mean age 11 yrs MVC - 44% Falls - 30% Sports - 22% Grade I - 26% Grade II - 23% Grade III - 35% Grade IV - 13% Grade V - 3% J Pediatr Surg 45:1311-1314, 2010

Children’s Mercy Isolated renal injury - (44%) Bed rest - 3.8 ± 1.9 d (mean) Hospital - 3.8 ± 3.1 d (mean) Blood tx – 15 pts Mean vol – 700 c Op – 6 pts – None for renal injury No tx in isolated renal injury No tx Grade IV or V injury Renal salvage – 99.1% One nephrectomy in pt w/ESRD HTN – 3 pts – 1 resolved Urinoma – 1 pt – resolved w/drainage J Pediatr Surg 45:1311-1314, 2010

Renal Trauma CMH is currently participating in multi-institutional, prospective, randomized trial with long-term follow-up Patients allowed out of bed when physically able Daily UA while in hospital Once discharged, weekly UA until hematuria is cleared Discharged when patients meet general discharge criteria 3 year follow-up for hypertension

References Fraser, JD, Aguayo P, Ostlie DJ, et al: Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int (2009) 25:125-132. Holcomb GW III, Murphy JP. Ashcraft’s Pediatric Surgery. 5th ed. Philadelphia, PA: Saunders An Imprint of Elsevier, 2010. Nerli RB, Metgud T, Patil S, et al: Severe renal injuries in children following blunt abdominal trauma: selective management and outcome. Pediatr Surg Int (2011) 27:1213-1216 Suson KD, Gupta AD, Wang MH. Bloody urine after minor trauma in a child: isolated renal injury versus congenital anomaly? J Pediatr. (2011) 159:870.

QUESTIONS www.cmhclinicaltrials.com Finally, until a more efficacious, more cost effective and more efficient (with regard to health care providers and families) antibiotic regimen is identified, this study supports the use of single day dosing of ceftriaxone/metronidazole as the initial treatment regimen in children with perforated appendicitis. www.cmhclinicaltrials.com