Predicting surgical exploration in renal trauma

Resultados de la atención de los pacientes con trauma renal ingresados a un centro de trauma nivel 1

Introducción. El debate acerca del manejo de los pacientes con trauma renal continúa, pero cada vez se avala más la estrategia conservadora. En este trabajo se presentan los resultados del manejo no operatorio en trauma renal, evaluando las variables que determinaron fallas en el tratamiento y sus conductas posteriores. Métodos. Estudio observacional descriptivo y retrospectivo. Se incluyeron pacientes mayores de 15 años con trauma renal confirmado con tomografía. Se excluyeron pacientes intervenidos en las primeras cuatro horas, trasplantados renales, y con nefrectomía previa. Se consignaron variables demográficas, signos vitales, características de la lesión, manejo y desenlaces. Resultados. Se incluyeron 97 pacientes, de los cuales el 82,5 % (n=80) tuvieron manejo conservador. El trauma cerrado ocurrió en el 56,7 % (n=55) y las lesiones denominadas de alto grado correspondieron al 67 % (n=65). Los principales hallazgos fueron dolor abdominal, hematuria macroscópica y heridas en el trayecto lumbar. El 73,2 % (n=71) tenían lesiones asociadas y el 31,9 % (n=31) necesitó transfusión. Los pacientes con fracaso en el manejo conservador tenían mayor edad, menor puntaje en la escala de coma de Glasgow y trauma asociado. La eficacia del manejo no operatorio fue del 83 % (n=67). La estancia hospitalaria de seis días y la mortalidad del 9,3 % (n=9); no estuvo relacionada exclusivamente con el trauma renal sino con la gravedad del trauma. Discusión. El trauma renal no es infrecuente y generalmente se asocia a otras lesiones. El manejo conservador ha demostrado reducción en las intervenciones innecesarias, complicaciones asociadas y nefrectomías.

External validation of a nomogram predicting risk of bleeding control interventions after high-grade renal trauma: The Multi-institutional Genito-Urinary Trauma Study

BACKGROUND

Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers.

METHODS

We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI).

RESULTS

Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9-2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44-6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84-0.92).

CONCLUSION

Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level III.

A nomogram predicting the need for bleeding interventions after high-grade renal trauma: Results from the American Association for the Surgery of Trauma Multi-institutional Genito-Urinary Trauma Study (MiGUTS)

BACKGROUND

The management of high-grade renal trauma (HGRT) and the indications for intervention are not well defined. The American Association for the Surgery of Trauma (AAST) renal grading does not incorporate some important clinical and radiologic variables associated with increased risk of interventions. We aimed to use data from a multi-institutional contemporary cohort to develop a nomogram predicting risk of interventions for bleeding after HGRT.

METHODS

From 2014 to 2017, data on adult HGRT (AAST grades III-V) were collected from 14 level 1 trauma centers. Patients with both clinical and radiologic data were included. Data were gathered on demographics, injury characteristics, management, and outcomes. Clinical and radiologic parameters, obtained after trauma evaluation, were used to predict renal bleeding interventions. We developed a prediction model by applying backward model selection to a logistic regression model and built a nomogram using the selected model.

RESULTS

A total of 326 patients met the inclusion criteria. Mechanism of injury was blunt in 81%. Median age and injury severity score were 28 years and 22, respectively. Injuries were reported as AAST grades III (60%), IV (33%), and V (7%). Overall, 47 (14%) underwent interventions for bleeding control including 19 renal angioembolizations, 16 nephrectomies, and 12 other procedures. Of the variables included in the nomogram, a hematoma size of 12 cm contributed the most points, followed by penetrating trauma mechanism, vascular contrast extravasation, pararenal hematoma extension, concomitant injuries, and shock. The area under the receiver operating characteristic curve was 0.83 (95% confidence interval, 0.81-0.85).

CONCLUSION

We developed a nomogram that integrates multiple clinical and radiologic factors readily available upon assessment of patients with HGRT and can provide predicted probability for bleeding interventions. This nomogram may help in guiding appropriate management of HGRT and decreasing unnecessary interventions.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level III.

Traumatic kidney injuries: A systematic review and meta-analysis

BACKGROUND

Traumatic kidney injury is an infrequent event with a wide range of injury patterns. The aim of this paper is to review the incidence, mechanisms of injury, diagnostic methods, and therapeutic indications of renal injury according to the most recent evidence and to perform an analysis of mortality rates on these patients.

OBJECTIVES

To perform a systematic review of the literature and a meta-analysis on traumatic kidney injuries.

DATA SOURCES

A literature search was performed using PubMed, Embase, and Scopus databases. Articles published in English, French and Spanish were selected from 1963 to 2018. MeSH terms utilized were renal trauma, kidney trauma, blunt renal trauma, and penetrating renal trauma.

STUDY PARTICIPANTS

The eligibility criteria included only original and human subject articles. Articles not involving human patients, cancer related, review articles, surveys, iatrogenic injuries, pediatric patients, and case reports were excluded from this search.

RESULTS

Forty-six articles met the inclusion criteria of which 48,660 patients were identified and included in this review. Gender was reported in 32,918 cases, of which 75.3% of patients were male with a mean age of 33 years. Of the 44,865 patients where the mechanism of injury was described, we identified 36,086 (80.5%) patients that sustained blunt trauma, while 8,779 (19.5%) were due to penetrating mechanisms. Twenty one series with a total of 31,689 patients included the mortality rate. Overall mortality rate with exact binomial 95% confidence interval estimated via random effects model was 6.4% (4.8%-8.4%).

CONCLUSIONS

Non-operative management has become the standard in renal trauma management with good results in morbidity and mortality. This has resulted in a decrease in the number of unnecessary iatrogenic nephrectomies and potential improvement in a patient's quality of life. When an invasive treatment is necessary, angioembolization for active bleeding or nephrorrhaphy is usually sufficient.

Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study

BACKGROUND

The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for high-grade renal trauma (HGRT). We aimed to describe the contemporary management of HGRT in the United States and also evaluate clinical factors associated with nephrectomy after HGRT.

METHODS

From 2014 to 2017, data on HGRT (American Association for the Surgery of Trauma grades III-V) were collected from 14 participating Level-1 trauma centers. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Management was classified into three groups-expectant, conservative/minimally invasive, and open operative. Descriptive statistics were used to report management of renal trauma. Univariate and multivariate logistic mixed effect models with clustering by facility were used to look at associations between proposed risk factors and nephrectomy.

RESULTS

A total of 431 adult HGRT were recorded; 79% were male, and mechanism of injury was blunt in 71%. Injuries were graded as III, IV, and V in 236 (55%), 142 (33%), and 53 (12%), respectively. Laparotomy was performed in 169 (39%) patients. Overall, 300 (70%) patients were managed expectantly and 47 (11%) underwent conservative/minimally invasive management. Eighty-four (19%) underwent renal-related open operative management with 55 (67%) of them undergoing nephrectomy. Nephrectomy rates were 15% and 62% for grades IV and V, respectively. Penetrating injuries had significantly higher American Association for the Surgery of Trauma grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy.

CONCLUSION

Expectant and conservative management is currently utilized in 80% of HGRT; however, the rate of nephrectomy remains high. Clinical factors, such as surrogates of hemodynamic instability and metabolic acidosis, are associated with nephrectomy for HGRT; however, higher renal injury grade and penetrating trauma remain the strongest associations.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III; Therapeutic study, level IV.

The epidemiology of renal trauma

Introduction

Nonoperative and minimally invasive management techniques for both blunt and penetrating renal trauma have become standard of care over the past decades. We sought to examine the modern epidemiology of renal trauma over the past decade.

Methods

A systematic review of PubMed from the past decade was conducted to examine adult and pediatric renal trauma. A total of 605 articles were identified. Of these, 15 adult and 5 pediatric articles met our a priori search criteria.

Results

There is a lack of uniform reporting of the renal trauma demographics precluding accurate assessment. Despite this, we were able to elucidate the following details. Renal trauma predominately affects young adult males, and the etiology is predominantly blunt. Among blunt injuries, motor vehicle crashes are most common among adult and pediatric patients. Nonoperative care was utilized in 94.8% of reviewed manuscripts with a 5.4% nephrectomy rate.

Discussion

There do not appear to be any startling changes in the presentation of adult and pediatric renal trauma over the past decade. Nonoperative care continues to be utilized as primary therapy. Increased attention on the reporting of renal trauma demographics is necessary to improve detection of trends.

Conclusions

Increased reporting of the presenting demographics of adult and pediatric renal trauma is encouraged to assist future assessment of epidemiology.

Urea

Urea is generated by the urea cycle enzymes, which are mainly in the liver but are also ubiquitously expressed at low levels in other tissues. The metabolic process is altered in several conditions such as by diets, hormones, and diseases. Urea is then eliminated through fluids, especially urine. Blood urea nitrogen (BUN) has been utilized to evaluate renal function for decades. New roles for urea in the urinary system, circulation system, respiratory system, digestive system, nervous system, etc., were reported lately, which suggests clinical significance of urea.