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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 31  |  Issue : 3  |  Page : 131-135

Clinical profile of patients with renal trauma: A cross-sectional observational study


Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka, India

Date of Submission16-Jul-2019
Date of Decision17-Mar-2020
Date of Acceptance21-Mar-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
J B Narendra
Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_50_19

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  Abstract 


Background: Renal trauma is generally managed with conservative or surgical treatment. This study evaluated the clinicoradiological profile of renal trauma patients (Grades I–V) and their management to determine the association of grade of renal trauma with length of hospital stay and type of treatment. Materials and Methods: This cross-sectional prospective observational study included patients with renal trauma aged >18 years. All the study patients underwent computed tomography for identification and grading of renal injury (I–V). Results: A total of 121 patients with renal trauma were included in this study. The mean (standard deviation) age was 42.36 (17.95) years. The majority of the study patients (n = 101) were managed conservatively. Rib fracture (n = 15) was the most common associated injury, and the majority had unilateral renal injury (n = 117). The distribution of patients according to grades of renal trauma was 21 (17.35%) in Grade I; 32 (26.45%), Grade II; 25 (20.66%), Grade III; 38 (31.40%), Grade IV; and 5 (4.13%), Grade V. Length of hospital stay was ranging from 7 to 15 days, increasing with the severity of grades from Grade I to Grade V. Grade of renal trauma was positively correlated with length of hospital stay, respectively (r = 0.390, P = 0.003). Grade of renal injury (P = 0.019) and type of treatment (P = 0.028) significantly affected the variations in the length of hospital stay. Conclusion: Conservative treatment is the preferred management approach for renal trauma; grade of renal trauma and type of treatment are responsible for variation in the length of hospital stay.

Keywords: Conservative, hospital stay, renal injury grade


How to cite this article:
Narendra J B, Ratkal C S, Keshavamurthy R, Karthikeyan V S. Clinical profile of patients with renal trauma: A cross-sectional observational study. Urol Sci 2020;31:131-5

How to cite this URL:
Narendra J B, Ratkal C S, Keshavamurthy R, Karthikeyan V S. Clinical profile of patients with renal trauma: A cross-sectional observational study. Urol Sci [serial online] 2020 [cited 2020 Jul 12];31:131-5. Available from: http://www.e-urol-sci.com/text.asp?2020/31/3/131/287977




  Introduction Top


Management of renal trauma is possible with either operative or nonoperative approach; however, it majorly depends on the grade of the renal injury. For the management of low-grade (Grades I–III) renal injuries, conservative approach is preferred over operative one. The key reason behind this is the decreased rate of complications associated with conservative management.

There are two types of renal trauma. (i) Blunt renal injuries due to motor vehicle accidents, falls from a height, and contact sports. These injuries result in sudden deceleration or crush injuries that may affect the renal parenchyma or the vascular pedicle. (ii) Penetrating renal injuries, mainly caused by firearms, gunshot, and stab wound. These cause direct damage to the parenchyma, excretory system, or vascular structures and even violation of the peritoneum. There is always a high risk of bacterial growth within the hematoma or urine leakage that may require surgical debridement or even nephrectomy.[1],[2],[3],[4] However, appropriate selection of patients based on their hemodynamic stability and accurate staging can prevent surgical management in patients with penetrating renal trauma.[1],[5] A recent meta-analysis demonstrated that conservative management for renal trauma is the standard of care for lower as well as higher grade blunt and penetrating renal injuries.[6] Several previous studies have reported significantly higher morbidity and mortality rates with operative management compared to conservative management in case of blunt renal trauma.[7],[8],[9],[10] Other advantages of applying conservative management include avoiding laparotomies, kidney resections, and nephrectomies and reducing hospital costs.

There are very limited data on Indian patients. The present study aimed to evaluate the clinicoradiological profile of renal trauma patients (Grades I–V) and their management to determine the optimal management approach among Indian patients.


  Materials and Methods Top


A cross-sectional prospective observational study was conducted at the Department of Urology, Institute of Nephro Urology, Bangalore, India, during 2007–2014. The study was conducted in accordance with the ethical principles in the Declaration of Helsinki. Written informed consent was obtained from each participant before enrollment.

Patients of either sex, aged more than 18 years, admitted to the Department of Urology for renal trauma were included in the study.

The detailed medical history and demographic details (age, sex, length of hospital stay, grades of renal injury, type of treatment, side of involvement, and associated injuries) were collected for each patient.

All the study patients underwent computed tomography for identification and grading of renal injury. Renal injury was graded from Grade I to Grade V according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scale.[11] Grade I renal injury can be characterized by organ contusion with microscopic or gross hematuria with normal imaging findings and cases of nonexpanding subcapsular hematomas with no parenchymal laceration. Grade II renal injury is defined as nonexpanding perinephric (perirenal) hematomas confined to the retroperitoneum or superficial cortical lacerations <1 cm in depth without collecting system injury. Grade III includes renal lacerations >1 cm in depth without collecting system injury. Grade IV renal injury can be defined as renal lacerations extending through the renal cortex, medulla, and collecting system or injuries involving the main renal artery or vein with contained hematoma and segmental infarctions without associated lacerations. Grade V injuries are shattered kidney, ureteropelvic junction avulsions, or complete laceration (avulsion) or thrombosis of the main renal artery or vein that devascularizes the kidney.

The patients who had unsuccessful management with nonoperative approach were treated with surgical procedures (retrograde pyelogram, double-J (DJ) stenting, percutaneous nephrolithotomy, open drainage, ultrasound-guided aspiration, and nephrectomy).

Statistical analyses were performed using Statistical Package for the Social Sciences version 23.0 (IBM, Chicago USA). Analyses of categorical variables using the Chi-squared test and quantitative variables using one-way ANOVA were conducted. Games–Howell post hoc analysis of ANOVA was employed for multiple group comparison. Correlation analysis was performed using Spearman's correlation coefficient test. Multiple linear regression analysis was used to find the variation in length of hospital stay due to variation in age, gender, type of treatment, side of renal involvement, and associated injuries. P <0.05 was considered to be statistically significant.


  Results Top


A total of 121 patients with renal trauma were enrolled in the study. In patients with renal trauma, the mean (standard deviation [SD]) age was 42.36 (17.95) with 103 men (85.12%) and 18 women (14.88%).

The majority of the patients (n = 101, 83.47%) with renal trauma were managed conservatively, whereas only 20 patients (16.53%) were managed surgically. The mean (SD) hospital stay was 11.38 (6.94) days. Fifty-four patients (44.63%) had injury on the right side and 63 (52.07%) on the left side and four (3.30%) patients had bilateral renal injury. The distribution of patients based on the AAST classification of renal trauma was 21 (17.35%) in Grade I; 32 (26.45%), Grade II; 25 (20.66%), Grade III; 38 (31.40), Grade IV; and 5 (4.13%), Grade V.

The most commonly associated injuries were rib fracture in 15 (12.39%) patients; urinoma and liver injury, 4 (3.30%) patients each; and hemothorax, pelvic hematoma, hemoperitoneum, and femur fracture in 2 (1.65%) patients each. However, 90 (74.38%) patients did not report any associated injury. Overall, 23.14% of the patients (n = 28) required surgical intervention for renal trauma: retrograde pyelography (6.61%), DJ stent (8.26%), percutaneous drain (1.65%), open drainage (1.65%), ultrasound-guided aspiration (1.65%), and nephrectomy (3.30%) [Table 1].
Table 1: Demographic characteristics of patients with renal trauma

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The mean (standard error [SE]) age was 33.2 (4.6), 32 (4.13), 28.3 (4.9), 31 (4.5), and 31.5 (8.5) years in patients with Grades I, II, III, IV, and V, respectively. The mean length of hospital stay was ranging from 7 to 15 days and showed an increasing trend with severity of grades from Grade I to Grade V. Length of hospital stay was 7, 11.5, 11.9, 14.3, and 15 days for patients with Grade I, II, III, IV, and V renal trauma. The majority of the patients were men (18 [85.71%], 27 [84.38%], 19 [76%], 35 [92.11%], and 4 [80%] patients with Grade I, II, III, IV, and V renal trauma, respectively) [Table 2].
Table 2: Analysis of gender, type of treatment, side of involvement, and associated injuries in different grades of renal trauma

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In patients with Grade I, II, III, IV, and V renal trauma, respectively, 14 (66.67%), 31 (96.87%), 23 (92%), 29 (76.32%), and 4 (80%) patients were managed conservatively, whereas the remaining patients underwent surgery. Patients with Grade III, IV, and V renal trauma had unilateral renal injury, whereas, in patients with Grades I and II, the majority had unilateral renal injury (n = 20, 95.24%, and n = 29, 90.63%, respectively) and only four patients had bilateral renal injury (n = 1, 4.76%, and n = 3, 9.37%, respectively). Associated injuries were observed in patients with Grades I (n = 5, 23.81%), II (n = 9, 28.13%), III (n = 10, 40%), and IV (n = 7, 18.42%). However, a numerical comparison of the associated injuries of groups involving collecting duct systems (Grades IV and V) and without involving collecting duct systems (Grades I, II, and III) demonstrated a total of 7 patients (16.27%) and 24 patients (30.76%) in respective groups with associated injuries. No death was reported in the study population [Table 2].

The grade of renal trauma was positively correlated with length of hospital stay (r = 0.390, P = 0.003). Type of treatment was not associated with grade of renal injury, age, gender, side of renal involvement, and associated injuries.

There was no significant difference in age and length of hospital stay between different grades of renal trauma. Games–Howell post hoc analysis of ANOVA was used for multiple group comparison. When patients with Grade I were compared with those with Grade IV, a statistically significant mean difference was observed in length of hospital stay (mean difference [SE] = −7.33 [3.1], P = 0.009) [Table 3].
Table 3: Multiple group comparison of age and length of hospital stay in different grades of renal trauma

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In the regression model, age, sex, grade of renal trauma, type of treatment, side of renal injury, and associated injuries were not good fit to explain variation in length of hospital stay (r = 0.438; r2= 0.192; adjusted r2= 0.095; P = 0.087). Only 19.2% of the variation in length of hospital stay could be explained by variation in these independent variables. When the effect of independent variables on each other was adjusted, it reduced further to only 9.5%. However, type of treatment (P = 0.028) and grade of renal injury (P = 0.019) significantly affected the variations in the length of hospital stay [Table 4].
Table 4: Multiple linear regression analysis

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  Discussion Top


Since the last decade, management of renal trauma cases has displayed a drastic change from surgical approach to the conservative one, which includes nonoperative methods.[12],[13],[14],[15] The present study attempted to evaluate the clinicoradiological profile of renal trauma patients (Grades I–V) and their management to determine the optimal management approach among Indian patients.

In the present study, the mean age was 42.36 years and the majority of the patients were men. These observations corroborate the previous studies showing the incidence of renal trauma being most prevalent in men from the age group of 31–38 years.[14],[15],[16],[17],[18],[19]

The most common approach used in this study for the management of renal trauma was the conservative one (83.47%), with the majority of the patients having unilateral injury (96.70%). The distribution of patients according to grades of renal trauma was comparable from Grade I to Grade IV, and the number of patients with Grade V was the lowest. A systematic review of 605 articles reported that, of the 10,935 renal trauma patients, the distribution of renal injuries was Grade I (26%), Grade II (28%), Grade III (20%), Grade IV (19%), and Grade V (7%). These observations are in agreement with the present study.[16]

Previous studies have reported management of renal trauma with nonoperative approach in 84% - 95% of the patients, with 2.7%–5.4% of the patients reporting failure.[15],[16] In a study by Ząbkowski et al., most of the cases were treated with conservative approach and had good outcomes for the 27 cases of Grade I and Grade II trauma. They were unable to successfully manage and treat Grade III and Grade IV injuries conservatively, except for 1 out of 10 Grade III injuries and 1 out of 4 Grade IV injuries.[17]

The present study reported 28 (23.14%) patients who required surgical interventions for renal trauma. These include retrograde pyelography (6.61%), DJ stent (8.26%), percutaneous drain, open drainage, ultrasound-guided aspiration (1.65%, each), and nephrectomy (3.30%). A study by Bjurlin et al. reported only 16.6% of the renal traumas were managed surgically, whereas 83.4% were managed nonoperatively. Nephrectomy (42.4%) and angiography and angioembolization (31.7%) were the most common surgical interventions used.[15]

In the present study, the overall length of hospital stay was ranging from 7 to 15 days and showed an increasing trend with severity of grades from Grade I to Grade V. Therefore, patients with Grade IV and Grade V renal trauma require a longer duration of hospital stay for better management of the injury. A study by Lanchon et al. reported 25 days and 12 days of hospital stay for surgically managed and conservatively managed renal trauma patients, respectively, suggesting that significantly longer duration of hospital stay is required for surgically managed patients.[20]

Bjurlin et al.'s study observations demonstrated that the increasing renal injury grades were associated with increasing risk of failing nonoperative management. The likelihood of nonoperative management failure increased with increasing renal grade injury where Grade III (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.35–2.90), Grade IV (OR, 9.79; 95% CI, 7.04–13.63), and Grade V (OR, 9.45; 95% CI, 6.02–14.86) renal injuries were associated with a statistically significantly increased likelihood of nonoperative failure compared with Grade I (P< 0.001).[15] This study did not analyze the risk factors of nonoperative failure compared between different grades.

The present study reported a positive association of renal trauma grade with length of hospital stay (r = 0.390, P = 0.003). These results support the longer duration of hospital stay required for patients with a higher grade in this study and suggest that severity of renal trauma is responsible for long duration of hospital stay.

Multiple linear regression analysis was used to find the variation in length of hospital stay due to variation in age, gender, type of treatment, side of renal involvement, and associated injuries. Only 19.2% of the variation in length of hospital stay could be explained by variation in these independent variables (P = 0.087). The type of treatment (P = 0.028) and grade of renal injury (P = 0.019) significantly affected the variations in the length of hospital stay. These results suggest that these two variables independently predicted the variation in length of hospital stay.

The present study did not compare outcomes of conservative and surgical approaches which were examined in several previous studies. However, a comparison of outcomes according to grades of renal trauma was analyzed in very limited studies.


  Conclusion Top


The present study's observations revealed that conservative treatment was the most commonly used approach for management of all grades of renal trauma. The common clinical characteristics were unilateral renal injury and rib fractures as a cause of injury. Grades of renal trauma and type of treatment are independent factors responsible for variation in length of hospital stay among Indian patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Bjurlin MA, Fantus RJ, Fantus RJ, Villines D. Comparison of nonoperative and surgical management of renal trauma: Can we predict when nonoperative management fails? J Trauma Acute Care Surg 2017;82:356-61.  Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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