. 120 .
Chinese Journal of Traumatology 2011; 14(2):120-122
Grade 4 renal injury: current trend of management and
future directions
Yiu Ming Ho* and Michael Schuetz
【Abstract】The management of blunt renal trauma
has been evolving. The past management largely based on
American Association for Surgery of Trauma (AAST) grad-
ing system, i.e. necessitated a computed tomography (CT)
scan. Although the CT scan use is increasing and becomes
the standardized mode of investigation, AAST grading no
longer plays the sole role in the decision of surgical
interventions. Two case reports of blunt renal trauma man-
aged successfully by conservative methods are presented.
Case one was an 18 year-old boy who had a fall when
riding a motorbike at 20 km/h with a helmet and full protec-
tive equipments. He was landed by his left flank onto a rock.
Contrast abdominal CT revealed a 4 cm, grade III splenic
tear and a grade IV left kidney injury with large perirenal
haematoma. His international severity score (ISS) was 34.
He was managed conservatively with bed rest and frequent
serum haemoglobin monitoring. Subsequent CT with de-
layed contrast revealed stable perirenal haematoma with
urine extravasation which was consistent with a grade IV
B
lunt renal traumas are uncommon and com-
posite a wide spectrum of severity. The trau-
mas can vary from mild contusion of kidney
parenchyma to the avulsion of renal pedicles causing
infarction of the entire kidney. American Association
for Surgery of Trauma (AAST) grading system has been
used to classify different severity of renal injury from
grade 1 to grade 5. Two cases of grade 4 blunt renal
trauma will be presented and the implication of AAST
grading to the management of blunt renal traumas will
be discussed.
DOI: 10.3760/cma.j.issn.1008-1275.2011.02.013
Traum a Service, Princess Alexand ra Hosp ital,
Brisbane, Queensland 4102, Australia (Ho YM and Schuetz
M)
*Corresponding author: Tel: 61-07-31762111, E-mail:
Yiu_Ming_Ho@health.qld.gov.au
renal injury. Case two was a 40 year-old male who had a
motor bike accident on a racetrack when he was driving at
80 to 100 km/h, wearing a helmet. He lost control and hit
onto the sidewall of the racetrack. Contrast abdominal CT
revealed a grade IV left renal injury with a large urine
extravasation. His renal injury was managed conservatively
with interval delayed phase CT of the abdomen. A repeat
CT on abdomen was performed five months after the initial
injury which revealed no residual urinoma.
In this study, moreover, a review of the literature to the
management of blunt renal trauma was conducted to dem-
onstrate the trend of increasing conservative management
of such traumas. Extra radiological parameters may guide
future decision making. However, the applicability of data
may be limited until randomized trials are available.
Key words: Renal trauma; International classifica-
tion of diseases; Therapeutics
Chin J Traumatol 2011; 14(2):120-122
CASE REPORT
Case one
An 18 year-old boy had a fall when he was riding a
dirt motorbike at 20 km/h with a helmet and full protec-
tive equipments. He was landed by his left flank onto a
rock. On presentation to an emergency department,
he was fully conscious and complained of left flank pain.
He was haemodynamically stable with intravenous fluid
(systolic blood pressure>90 mm Hg, 1 mm Hg=0.133
kPa). Focused assessment with sonography for trauma
(FAST) revealed no free peritoneal blood. Urine analy-
sis showed microscopic haematuria. Serum haemo-
globin was 110 g/L. Contrast abdominal computed to-
mography (CT) revealed a 4 cm, grade III splenic tear
and a grade IV left kidney injury with large perirenal
haematoma (Figure 1). His international severity score
(ISS) was 34. He was managed conservatively with bed
rest and frequent serum haemoglobin monitoring. Sub-
sequent CT with delayed contrast revealed stable peri-
renal haematoma with urine extravasation which was
Chinese Journal of Traumatology 2011; 14(2):120-122
consistent with a grade IV renal injury (Figure 1). His
haemoglobin was stable and subsequently discharged
on day 5 of his hospital stay.
Case two
A 40 year-old male had a motor bike accident on a
racetrack when he was driving at 80 to 100 km/h. He
lost control and hit onto the sidewall of the racetrack.
He was wearing a helmet. He was fully alert and
haemodynamically stable on arrival to an emergency
department. The primary survey revealed bilateral
haemothoraces, fracture of the eleventh and the twelfth
thoracic vertebrae. Abdominal examination showed left
flank tenderness but with neither peritonism nor a pulsatile
mass. Urine analysis showed microscopic haematuria.
Contrast abdominal CT revealed a grade IV left renal in-
jury with a large urine extravasation (Figure 2). His renal
injury was managed conservatively with interval delayed
phase CT of the abdomen. The patient stayed in the
spinal injury unit for 38 days for rehabilitation due to his
thoracic injuries. A repeat abdominal CT was performed
five months after the initial injury which revealed no re-
sidual urinoma.
DISCUSSION
High grade (grade IV and V) renal injuries are un-
common injuries in traumas. The reported incidence is
1%-2% of all traumas.1 The trauma registry of Princess
Alexandra Hospital, which is a tertiary referral hospital,
was reviewed to identify trauma cases with renal injuries.
The registry recorded 24 renal blunt traumas from 2008
Table 1. Management of high grade blunt renal trauma
Studies Number (Grade 4, Grade 5)
Santucci (2000) 4
2047
Kuo (2002) 8
95 (16,8)
Wright (2006) 7
6892 (530, 228)
Elashry (2008) 9
72 (57, 15)
Dugi (2010) 1
73 (73,-)
. 121 .
to 2009 and two of them were high grades. All cases
with renal injuries were investigated by CT scans, while
CT cystograms were performed in cases of high grade
renal injuries to evaluate the full urinary tract.
Management of blunt renal trauma has been evolving.
The past management largely based on AAST grading
system, which was developed in 1989. The original idea
was to standardize classification of organ injury for re-
search purposes.2 A number of studies confirmed the
correlation between grading and the likelihood of surgi-
cal interventions,3 either renorrhaphy or nephrectomy.
The rate of surgical intervention in blunt renal trauma
has reduced with time. Pilot study by Santucci et al4
(2000) evaluated 2 047 blunt renal traumas and con-
cluded that more than 75% grade 4 renal blunt trauma
needed surgical interventions. The rate of surgical man-
agement of grade 4 renal injury due to blunt traumas
had gradually decreased to 35% in 20101 (Table 1). The
decrease of surgical interventions reflected better un-
derstanding of the natural history of blunt renal trauma.
Besides, the advancement of radiological interventions
also obviates surgery in selected renal injuries.5 Some
previous indications for surgical interventions, such as
urinary extravagation, have been invalidated.6
Grading no longer plays the sole role in assessing
the risk of surgical intervention. Dugi1 (2010) identified
that, apart from AAST grading, perirenal hematoma size>
3.5 cm, presence of intravascular contrast extravasa-
tion and presence of complex lacerations increased risk
of surgical intervention.4
Management of grade 4 injury Management of grade 5 injury
22% conservative 0 conservative
9% nephrectomy 86% nephrectomy
69% renorrhaphy 7% renorrhaphy
7% undocumented
56.2% conservative 25% conservative
25% nephrectomy 62.5% nephrectomy
18.8% exploratory laparotomy only 12.5% exploratory laparotomy only
77.6% conservative 44.2% conservative
22.4% nephrectomy 55.8% nephrectomy
84.2% conservative 20% conservative
15.8% surgical 80% surgical
89% conservative
11% surgical —
. 122 .
Figure 1. Axial (A) and sagittal (B) CT showed the macerated left kidney with multiple lacerations extending to the renal pelvis. Axial CT
(C) in delayed phase showed extravasation of contrast in urine. Figure 2. Axial CT showed large extravasation of contrast in urine
forming an urinoma.
All examined studies were retrospective study,
which can estimate the rate of certain risk factors for
surgical intervention, e.g. AAST grade. The risk factors
do not necessitate surgical interventions like the indi-
cations but help in stratify patients into different risk
categories. The indications of surgical intervention are
still similar to other viscera injuries including life threat-
ening haemorrhage, pedicle avulsion, expending and
pulsatile haematoma,7 renal vein laceration, sepsis and
presence of avascular segment(s).8
In conclusion, the rate of surgical management of
high grade blunt renal trauma has been decreasing.
Absolute indications for surgical interventions are
illustrated. AAST grading gives us a relative risk for
surgical intervention rather than as an indication for
surgery.
Competing interest: The corresponding author is
not a recipient of a research scholarship. The paper is
not based on a previous communication to a society or
meeting.
REFERENCES
1. Dugi DD 3rd, Morey AF, Gupta A, et al. American Asso-
ciation for the Surgery of Trauma grade 4 renal injury
Chinese Journal of Traumatology 2011; 14(2):120-122
substratification into grades 4a (low risk) and 4b (high risk). J Urol
2010;183(2):592-597.
2. Moore EE. Organ injury scaling: spleen, liver, and kidney.
J Trauma 1989;29(12):1664-1666.
3. Hammer CC, Santucci RA. Effect of an institutional policy
of nonoperative treatment of grades I to IV renal injuries. J Urol
2003;169(5):1751-1753.
4. Santucci RA, McAninch JW. Diagnosis and management of
renal trauma: past, present and future. J Am Coll Surg 2000;191
(4):443-451.
5. Breyer BN, McAninch JW, Elliott SP, et al. Minimally
invasive endovascular techniques to treat acute renal hemorrhage.
J Urol 2008;179(6):2248-2253.
6. Matthews LA, Smith EM, Spirnak JP. Nonoperative treat-
ment of major blunt renal lacerations with urinary extravasation. J
Urol 1997;157(6):2056-2058.
7. Wright JL, Nathens AB, Rivara FP, et al. Renal and extrare-
nal predictors of nephrectomy from the national trauma data bank.
J Urol 2006;175(3 Pt 1):970-975.
8. Kuo RL, Eachempati SR, Makhuli MJ, et al. Factors affect-
ing management and outcome in blunt renal injury. World J Surg
2002;26(4):416-419.
9. Elashry OM, Dessouky BA. Conservative Management of
major blunt renal trauma with extravasation: a viable option? Eur
J Trauma Emerg Surg 2009;35(2):115-123.
(Received November 5, 2010)
Edited by LIU Gui-e