Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 167-169

Conservative management of hemodynamically stable patient with grade V renal trauma: Case presentation and review of the literature


Department of Urology, General Hospital of Athens G.N.A. “G. Gennimatas,” Athens, Greece

Date of Submission07-Apr-2020
Date of Decision30-Apr-2020
Date of Acceptance14-May-2020
Date of Web Publication13-Aug-2021

Correspondence Address:
Charalampos Fragkoulis
Thessalias 24b Street, Kato Halandri, Athens
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_26_21

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  Abstract 


Renal trauma is a major health problem involving mostly young patients. It is estimated that renal trauma is diagnosed in almost 5% of all trauma patients. Patients diagnosed with Grade V renal trauma require surgical intervention and usually nephrectomy. The aim of this study is to present a case of Grade V renal trauma in a hemodynamically stable patient treated conservatively in our department. A 24-year-old male was admitted to the urology department due to Grade V left renal trauma after a motor accident. The patient presented with hematuria and was hemodynamically stable. A conservative approach was performed with close monitoring of hemodynamic status. Two red blood cells units was transfused. The patient remained hemodynamically stable and renal hematoma reduced in size in follow-up computed tomography. The patient was discharged in excellent clinical status after 17 days of hospitalization. Although Grade V renal trauma involving vascular injury requires immediate surgical intervention, in selected patients diagnosed with shattered kidney, a conservative approach may be successful provided that the patient remains hemodynamically stable and under close monitoring. Hemodynamic instability is an absolute indication for surgical exploration and possible nephrectomy.

Keywords: Grade V renal trauma, renal injury, shattered kidney


How to cite this article:
Fragkoulis C, Glykas I, Moschotzopoulos D, Aristas O, Papadopoulos G, Stathouros G, Ntoumas K. Conservative management of hemodynamically stable patient with grade V renal trauma: Case presentation and review of the literature. Hellenic Urology 2020;32:167-9

How to cite this URL:
Fragkoulis C, Glykas I, Moschotzopoulos D, Aristas O, Papadopoulos G, Stathouros G, Ntoumas K. Conservative management of hemodynamically stable patient with grade V renal trauma: Case presentation and review of the literature. Hellenic Urology [serial online] 2020 [cited 2022 May 22];32:167-9. Available from: http://www.hellenicurologyjournal.com/text.asp?2020/32/4/167/323814




  Introduction and Background Top


Renal trauma is a major health problem involving mostly young patients and more often males rather than females. It is estimated that renal trauma is diagnosed in almost 5% of all trauma patients.[1] All patients are classified according to the American Association for the Surgery of Trauma (AAST) renal injury scale to receive appropriate treatment, as it provides information about morbidity and predicts the risk for surgical intervention and nephrectomy.[2] As far as it concerns treatment, the absolute indication for surgical exploration is hemodynamic instability, the need to explore associated abdominal injuries, and the discovery of an expanding or pulsatile perirenal hematoma at laparotomy. Grade V renal trauma includes patients with vascular injury of the renal pedicle including avulsion or cases presenting with shattered kidney. As a result, Grade V renal vascular trauma is an absolute indication for exploration; however, in clinical practice, all Grade V cases (parenchymal and vascular) undergo surgical exploration.[3] In this paper, we present a case of Grade V renal trauma in a hemodynamically stable patient treated conservatively in our department.


  Case Presentation Top


A 24-year-old male was transferred to the emergency department after a motor accident. During initial resuscitation, a Foley catheter was placed, and visible hematuria was present. The patient was hemodynamically stable, and according to the current protocol, he underwent full-body computed tomography (CT) which revealed left kidney Grade V parenchymal trauma (shattered kidney) [Figure 1]. Neither there was sign of vascular trauma nor was concomitant injury recorded. The patient remained hemodynamically stable with hemoglobin level of 12.2 ng/dl and was admitted to the urology department. The decision was to conservatively manage the patient with close monitoring of hemodynamic status. A transfusion of two units of red blood cells was performed when hemoglobin levels dropped to 9 ng/dl. The patient remained hemodynamically stable, and 48 h postadmission, a repeat CT was performed which revealed a large perirenal hematoma and signs of shattered kidney. No further transfusion was required, and a follow-up CT was performed 15 days after initial evaluation in which hematoma was reduced in size. The patient was discharged after 17 days of hospitalization, and another CT was performed 1 month later. Hematoma had almost disappeared, and the kidney appeared to be functional [Figure 2]. No signs of hypertension were recorded at follow-up.
Figure 1: Grade V renal trauma (shattered kidney)

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Figure 2: Follow-up computed tomography (1 month later)

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  Discussion Top


Assessment of overall renal injury severity is classified according to the AAST renal injury scale. This classification is based on the degree of renal parenchyma and blood vessel rupture and the extent of the subcapcapsular or perirenal hemorrhage. Grade V trauma is diagnosed in cases of shattered kidney or vascular injury of the renal pedicle or avulsion.[2] In clinical practice, most patients suffering from renal trauma are hemodynamically stable, and according to the current protocols, they undergo abdominal CT to evaluate trauma severity.[4] On the other hand, Grade V renal trauma usually presents with hemodynamic instability, and it is quite common that the patient also suffers from severe concomitant injuries; thus, the possibility of surgical exploration is remarkably high.[5]

Nowadays, based on modern imaging techniques and growing experience in the conservative management of renal trauma, the trend is toward a more conservative approach even in cases of severe renal trauma. Despite the fact that Grade V vascular trauma is an absolute indication for surgical intervention, in cases of hemodynamic stable patients diagnosed with shattered kidney (Grade V parenchymal trauma), a more conservative approach may be performed.[3],[6] In a case series presented by van der Wilden et al., including a total of 206 patients presenting with Grade IV or V renal trauma, 74.8% were managed nonoperatively (with the assistance of angiographic embolization for 25 patients). Nonoperative management failed for 12 of the 154 patients (7.8%).[7] In addition, Lanchon et al. presented their experience in nonoperative management of Grade IV/V patients with a total success rate of 82%. Severity of renal trauma influenced success rates with patients suffering from Grade V trauma presenting a success rate of 52% compared with 89% for Grade IV patients.[8]

In the current clinical practice, hemodynamic instability is an absolute indication for surgical exploration regardless of trauma severity. Surgical exploration is influenced by etiology and grade of injury, transfusion requirements, the need to explore associated abdominal injuries, and the discovery of an expanding or pulsatile perirenal hematoma at laparotomy.[9]


  Conclusion Top


Isolated Grade V renal trauma is extremely rare. In selected cases, in patients with hemodynamic stability and provided that renal pedicle vascular trauma is excluded, a conservative management may be possible under very close monitoring of vital signs. In any sign of hemodynamic instability, surgical exploration should be performed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Meng MV, Brandes SB, McAninch JW. Renal trauma: Indications and techniques for surgical exploration. World J Urol 1999;17:71-7.  Back to cited text no. 1
    
2.
Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, et al. Organ injury scaling: Spleen, liver, and kidney. J Trauma 1989;29:1664-6.  Back to cited text no. 2
    
3.
Shariat SF, Roehrborn CG, Karakiewicz PI, Dhami G, Stage KH. Evidence-based validation of the predictive value of the American Association for the Surgery of Trauma Kidney Injury Scale. J Trauma 2007;62:933-9.  Back to cited text no. 3
    
4.
Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW, et al. Evaluation and management of renal injuries: Consensus statement of the renal trauma subcommittee. BJU Int 2004;93:937-54.  Back to cited text no. 4
    
5.
Moudouni SM, Hadj Slimen M, Manunta A, Patard JJ, Guiraud PH, Guille F, et al. Management of major blunt renal lacerations: Is a nonoperative approach indicated? Eur Urol 2001;40:409-14.  Back to cited text no. 5
    
6.
Dantanarayana N, Ting F, Symons J, Evans D, Graham A. Isolated grade 5 renal trauma in a hemodynamically stable patient. Urol Case Rep 2016;4:30-2.  Back to cited text no. 6
    
7.
van der Wilden GM, Velmahos GC, Joseph DK, Jacobs L, Debusk MG, Adams CA, et al. Successful nonoperative management of the most severe blunt renal injuries: A multicenter study of the research consortium of New England Centers for Trauma. JAMA Surg 2013;148:924-31.  Back to cited text no. 7
    
8.
Lanchon C, Fiard G, Arnoux V, Descotes JL, Rambeaud JJ, Terrier N, et al. High grade blunt renal trauma: Predictors of surgery and long-term outcomes of conservative management. A prospective single center study. J Urol 2016;195:106-11.  Back to cited text no. 8
    
9.
Husmann DA, Gilling PJ, Perry MO, Morris JS, Boone TB. Major renal lacerations with a devitalized fragment following blunt abdominal trauma: A comparison between nonoperative (expectant) versus surgical management. J Urol 1993;150:1774-7.  Back to cited text no. 9
    


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