Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society

Abstract

BACKGROUND 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. METHODS Grading of Recommendations Assessment, Development and Evaluation 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 performed. 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. RESULTS When comparing nonoperative management versus 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 nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%. CONCLUSION Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus 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. LEVEL OF EVIDENCE Guidelines study, level III.

Complications of urinary tract trauma: case reports

“…Kidney damage due to blunt or penetrating trauma to the abdomen is the most common type of damage to the urinary tract. According to the latest guidelines of 2019 (10) , non-surgical management is recommended for paediatric patients with blunt force kidney trauma of all grades. The only absolute indication for surgical treatment is lack of response to resuscitation, which manifests with persistent haemodynamic instability.…”

“…Kidney trauma complications in children also include arterial hypertension. In order to diagnose it early, regular routine blood pressure measurements are recommended (10,13) . Trauma is the most common cause of death, disability and social inequality in the paediatric population.…”

“…According to the American Association for the Surgery of Trauma scale, kidney injury can be divided into 5 grades: grade I -contusion, sub-capsular haematoma, no parenchymal laceration; grade IInonexpanding perirenal haematoma, parenchymal laceration of <1 cm; grade III -parenchymal laceration of >1 cm without damage to the pelvicalyceal system; grade IV -major laceration extending to the urinary collecting system, haemourinoma, segmental vessel damage, vascular thrombosis; grade V -shattered kidney, renal vascular pedicle damage. According to the current guidelines developed by the Eastern Association for the Surgery of Trauma (EAST) and Pediatric Trauma Society (PTS), in haemodynamically stable children, conservative management is recommended regardless of kidney trauma severity (10) . Other organs of the genitourinary system are damaged much less frequently.…”

A 7-year retrospective review of renal trauma in paediatric patients in Johannesburg

“…14,15 The American Association for Surgery of Trauma (AAST) organ injury scale based on CT findings grades renal injuries from I to V. 12 NOM of low-grade (AAST I-III) renal injuries is well-accepted whilst less evidence is available for management of high-grade (AAST IV-V) renal injuries. 16,17 Failure to respond to resuscitation, which manifests as haemodynamic instability, is the only absolute indication for operative management. 16,17 This retrospective study aimed to document paediatric renal trauma in a level 1 trauma centre in a low-to middleincome country (LMIC), to identify deficits in care to improve outcomes at our institution and to compare these results to those found in local and international literature.…”

“…16,17 Failure to respond to resuscitation, which manifests as haemodynamic instability, is the only absolute indication for operative management. 16,17 This retrospective study aimed to document paediatric renal trauma in a level 1 trauma centre in a low-to middleincome country (LMIC), to identify deficits in care to improve outcomes at our institution and to compare these results to those found in local and international literature.…”