Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma.
GRADE methodology was used to aid with the development of these evidence based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was done. Fifty one articles were used to inform the statements presented in the guidelines. When possible a meta-analysis with forest plots was created and the evidence was graded.
When comparing non-operative management vs. operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed non-operatively. We found that in pediatric patients with high grade (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angio-embolization has a decreased rate of renal loss compared to surgical intervention. We found the rate of post-traumatic renal hypertension to be 4.2%.
Based on the completed meta-analyses and GRADE profile we are making the following recommendations: 1. In pediatric patients with blunt renal trauma of all grades, we strongly recommend non-operative management vs. operative management in hemodynamically stable patients. 2. In hemodynamically stable pediatric patients with high grade (AAST grade III-V) renal injuries, we strongly recommend angio-embolization vs. surgical intervention for ongoing or delayed bleeding. 3. In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma.
Guidelines LEVEL OF EVIDENCE: III.
The journal of trauma and acute care surgery. 2019 Feb 07 [Epub ahead of print]
Judith C Hagedorn, Nicole Fox, Jonathan S Ellison, Robert Russell, Cordelie E Witt, Kristen Zeller, Paula Ferrada, John M Draus
Department of Urology, University of Washington, Seattle, WA., Department of Surgery, Division of Pediatric Surgery, Cooper University, Camden, NJ., Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI., Children's of Alabama, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL., Department of Surgery, University of Washington, Seattle, WA., Department of Surgery, Section of Pediatric Surgery, Wake Forest School of Medicine, Wake Forest, NC., Department of Surgery, Virginia Commonwealth University, Richmond, Virginia., Department of Surgery, Division of Pediatric Surgery, University of Kentucky, Lexington, Kentucky.