ª Springer Science+Business Media New York 2016 Abdom Radiol (2016)

Abdominal DOI: 10.1007/s00261-016-0731-x

Radiology

Renal trauma: imaging evaluation and

implications for clinical management
Suzanne T. Chong,1 Jill R. Cherry-Bukowiec,2 Jonathon M.G. Willatt,3 Ania Z. Kielar4
1
Division of Emergency Radiology, Department of Radiology, University of Michigan, 1500 E. Medical Center Drive TC-B1-140D,
SPC 5302, Ann Arbor, MI 48109-5302, USA
2
Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
3
Abdominal and Interventional Radiology, Department of Radiology, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
4
Division of Abdominal Imaging, Department of Radiology, University of Ottawa, Ottawa, ON, Canada

Abstract per year. Renal injuries are present in up to 5% of trauma

Severe renal injuries are usually associated with multi-
system injuries, may require interventional radiology to
control hemorrhage and improve the chances for renal
salvage, and are more likely to fail nonoperative man-
agement. However, most renal injuries are mild in
severity and successfully managed conservatively. The
AAST classification is the most widely used system to
describe renal injuries and carries management and
prognostic implications. CT with intravenous contrast is
the imaging test of choice to assess for renal injuries.
Contrast extravasation indicating active bleeding should
be mentioned as its presence is predictive for failure of
nonoperative management. Radiologists play a critical
role in identifying renal injuries and should make every
effort to describe renal injuries according to the AAST
grading scheme to better inform the surgeon’s manage-
ment decisions.
Key words: Computed tomography—Renal
trauma—AAST grading
Background: epidemiology, anatomic
considerations, and mechanisms of
injury
In adults, the kidney is the most commonly injured
genitourinary organ and the third most commonly in-
jured organ in adults following blunt trauma. Approxi-
mately 245,000 cases of renal trauma occur worldwide
Correspondence to: Suzanne T. Chong; email: suzchong@med.umich.
edu
patients and in approximately 10% of abdominal trau-
mas [1, 2]. Nearly three-quarters of patients with renal
trauma are young and male [1]. In children and adoles-
cents, the kidney is the most commonly injured organ,
accounting for more than 60% genitourinary injuries and
10–20% of blunt abdominal injuries [3–5]. Most renal
trauma in children is minor and occurs after the age of
5 years but increasing age is associated with worsening
severity of injuries as well as multisystem injuries [5, 6].
In both adult and pediatric patients, the vast majority of
renal injuries (90%) are due to blunt force trauma, most
commonly motor vehicle collisions, falls from great
heights, assaults, and sports related. A minority of renal
injuries, approximately 10%, is due to penetrating in-
juries such as gunshot and stab wounds. Gunshot
wounds cause some of the most complex injuries in the
urologic system, resulting in significant tissue damage
and fragmentation [7, 8]. Blast effect, in which the energy
from high velocity gunshots results in shock waves that
propagate into the adjacent soft tissues, further intensi-
fies the severity of injuries and results in tissue devascu-
larization [7, 9, 10]. Gunshot wounds are associated with
more severe injuries reflected by advanced AAST renal
grades and concomitant neurologic, vascular, and tho-
racoabdominal injuries that may complicate treatment
[7, 11].
In adults, the kidneys are protected from injury by
their high location in the retroperitoneum and by sur-
rounding adipose tissue and fascia, adjacent musculature
and vertebrae, and the overlying ribs [12]. In children and
adolescents, the larger size of the kidneys relative to the
abdominal cavity, weaker connective tissues and Ger-
ota’s fascia, less developed abdominal and paraspinal
musculature, and less ossified ribs all contribute to in-
creased susceptibility of the pediatric kidney to blunt
 S. T. Chong et al.: Imaging evaluation and implications for clinical management

trauma [13]. The pediatric kidney is more mobile on its

vascular pedicle and more caudally located in the abdo-
men, increasing its vulnerability to trauma. The energy
from trauma is distributed over a smaller body surface area
in children, which results in a higher sustained force of
impact [14]. The close proximity of the intra-abdominal
organs increases the likelihood of multiple organ injuries
[14]. Children are especially susceptible to marked flexion-
extension injuries, such as pedestrian vs. motorized vehicle
[15].
When sufficient force is inflicted, the kidneys are
thrust against the osseous structures, turning the nor-
mally protective ribs and vertebrae into agents of sig-
nificant injury. Because the kidneys are essentially
floating free in fat, anchored only at the renal pelvis and
vascular pedicle, they are especially susceptible to accel-
eration and deceleration injuries that rapidly and forcibly
dislocate the kidneys [16, 17]. These acceleration–decel-
eration injuries may tear the collecting system at the
ureteropelvic junction (UPJ) or produce intimal tears
that can result in partial or complete renal artery or vein
thrombosis. When severe renal injuries are present, a
high force mechanism can be inferred, and injuries to
other abdominal organs are often present [15, 16].
Kidneys that are structurally abnormal due to
developmental anomalies are more vulnerable to renal
trauma (Fig. 1). In this patient population, relatively
minor trauma can result in severe injuries and require
more aggressive treatment. The incidence of pre-existing
abnormalities is higher in children than adults, with renal
anomalies observed in 12.6–15.4% of pediatric kidney
injuries [18]. Kidneys that are abnormally enlarged (e.g.,
UPJ obstruction, autosomal recessive polycystic kidney
Fig. 1. Axial (A) and coronal (B) contrast-enhanced CT
disease, and renal masses most commonly Wilms tumor) shows multiple small hypoattenuating lesions, some con-
or abnormally located (e.g., crossed renal ectopia with or taining fat (arrowhead), represent angiomyolipomas (AML) in
without fusion and horseshoe kidney) are at greater risk a patient with tuberous sclerosis. The patient was involved in
of injury due to less anatomic shielding from the sur- low velocity blunt trauma and presented with flank pain. There
rounding structures [18]. Computer simulation has is a large left perinephric hematoma with prominent areas of
demonstrated that the dilated collecting system in the contrast extravasation (arrows) indicating active bleeding
hydronephrotic kidney amplifies applied force, poten- from a small laceration.
tially worsening the severity of injury [18]. The imaging
injury or physical exam concerning for renal injury e.g.,
findings of the traumatized kidney are often out of
rapid deceleration, significant blow to flank, rib fracture,
proportion to the severity of the traumatic injury [18].
significant flank ecchymosis, penetrating injury of abdo-
Depending on the extent of the pre-existing abnormali-
men, flank or lower chest, or (3) there is clinical concern
ties, accurate staging of renal injuries may be challenging
for renal injury based on physical findings, associated
but is important to direct management decisions [19].
abdominal injuries, or mechanism of injury.
Although the 2014 AUA guidelines do not specifically
Indications for imaging address the indications for imaging patients with pene-
The American Urologic Association (AUA) issued new trating trauma, the widely accepted indication is the
clinical guidelines in 2014 for imaging patients with sus- presence of hematuria or clinical suspicion for urinary
pected renal trauma and summarized in Table 1 [20]. tract injury [12, 21].
Contrast-enhanced computed tomography (CT) is rec- Also not specifically addressed by the AUA 2014
ommended in stable patients with blunt renal trauma who guidelines, imaging for suspected renal trauma in pedi-
possess (1) gross hematuria or microscopic hematuria and atric patients is generally regarded to be indicated if the
systolic blood pressure 90 mm Hg, (2) a mechanism of urinalysis reveals >50 red blood cells (RBC) per high
S. T. Chong et al.: Imaging evaluation and implications for clinical management

Table 1. Summary of AUA 2014 guidelines for imaging patients with suspected renal trauma [20]
Patient status and mechanism of injury Indications for imaging

Adults, blunt injury Gross hematuria

Pediatric patients, blunt injury
Adults, penetrating injury
Pediatric patients, penetrating injury
Microscopic hematuria and systolic blood pressure <90 mm Hg
Mechanism of injury or physical exam concerning for renal injury
Clinical concern for renal injury based on physical findings, abdominal injuries or mechanism of injury
Adult blunt injury indications
>50 RBC per HPF
Hematuria or clinical suspicion for urinary tract injury
Adult penetrating injury indications
>5 RBC per HPF

All patients should be hemodynamically stable. Imaging is indicated if the patient demonstrates any of the indications

Table 2. US versus CT for initial imaging of the pediatric patient with

powered field (HPF) in blunt injury and >5 RBC/HPF
in penetrating injury [2, 3].
Gross hematuria is considered the most reliable indica-
tor for significant renal injuries. Most significant renal in-
juries present with hematuria, and those with the most
severe injuries usually have gross hematuria [16, 17]. In one
series of patients with grade IV blunt and penetrating renal
injuries, hematuria was present in 88% of the patients (63%
gross, 25% microscopic) [15, 22, 23]. It is generally accepted
that in a trauma patient without gross hematuria and shock,
significant renal injuries are unlikely to be present [17].
However, the absence of hematuria does not exclude renal
injury. The degree of hematuria does not predict the severity
of renal injuries in either blunt or penetrating trauma nor is
there an absolute correlation between hematuria and the
presence or extent of renal injuries. Patients with UPJ
avulsion and up to 24% of patients with vascular pedicle
injuries may not have hematuria [17]. Renal pedicle avulsion
or acute segmental renal artery thrombosis can occur in the
absence of hematuria [15]. Imaging may be necessary based
solely on clinical suspicion for renal trauma particularly in
patients with penetrating trauma to the flank, lower thorax,
or the abdomen. In adults, microhematuria is present in only
a tiny percentage of hemodynamically stable trauma pa-
tients with significant renal injuries (up to 0.5%) and is not
an absolute indication for renal imaging [17].
Imaging of renal trauma in the pediatric population
should be performed using the ALARA principle (as low
as reasonably achievable) in order to minimize the risk of
radiation-induced malignancy. If CT is used nonselec-
tively as a routine screening test for suspected abdominal
trauma in children, too many children without significant
injuries will be exposed to unnecessary radiation [24]. Thus
in pediatric patients, CT is reserved for patients with severe
trauma (Table 2) [25]. Ultrasound can be safely performed
as the initial imaging test in hemodynamically stable pa-
tients in which the renal traumatic injuries are suspected to
be minor or moderate (AAST grades I–III) [5, 25, 26]. CT
may be necessary if ultrasound findings are discordant
with more significant clinical findings or if there is an
impediment to the use of sonography such as overlying
bandages.
suspected renal injuries
Ultrasound CT
Mild or moderate Severe injuries suspected
injuries suspected Unable to perform ultrasound
(AAST grades I-III) Initial ultrasound findings are
discordant with significant
clinical findings
All patients are hemodynamically stable
In adult and pediatric patients, hemodynamic insta-
bility is an indication for surgical exploration. It is
important to note that in children, hypotension is an
unreliable indicator of shock. Children can sustain severe
hypovolemia with blood losses of up to 45% of their
intravascular volume before their blood pressures drops
[14, 27]. Aside from this caveat of hypotension, the adult
parameters for imaging in suspected renal trauma (gross
hematuria, appropriate mechanism injury, and clinical
suspicion) can be applied to children without missing
significant renal injuries [28, 29].
Imaging techniques
Multi-detector computed tomography (MDCT)
With advances in CT technology in the past two decades,
MDCT with intravenous contrast has evolved into a
central role in the evaluation of patients with renal
trauma, particularly when severe or multisystem injuries
are suspected. With a single bolus of intravenous con-
trast, thin-section CT images can be rapidly acquired
that are highly sensitive and specific for renal injuries and
effective for detecting additional injuries. Imaging pro-
tocols vary amongst institutions but standard imaging at
most institutions consists of 0.625 mm collimated images
acquired helically that are reconstructed to 1.25–5.0 mm
for viewing with multiplanar reformatted images that
may be helpful for improved characterization of trau-
matic injuries. Imaging is performed during the late
corticomedullary phase which coincides temporally with
the portal venous phase that is optimal for imaging the
most commonly injured organs (liver, spleen) in
 S. T. Chong et al.: Imaging evaluation and implications for clinical management
abdominal trauma [21]. Delayed excretory phase images
obtained approximately 10–20 min after the initial
intravenous contrast injection are performed on a selec-
tive basis when there is sufficient concern for collecting
system injury. At our institution, delayed images are
obtained only if the initial portal venous CT study
demonstrates parenchymal lacerations that extend to the
collecting system (calyces or the renal pelvis) or if there is
increased perinephric fluid suggesting a urine leak.
Ultrasound (US)
Ultrasound is noninvasive, widely available, relatively inex-
pensive, and can be rapidly performed. It does not use ion-
izing radiation nor does it carry the risks of nephrotoxic and
allergic reactions from intravenous contrast administration
that CT possesses. At most institutions, FAST (Focused
Assessment by Sonography in Trauma) is performed as a
standard part of the trauma resuscitation to detect free
abdominal fluid. Ultrasound is highly operator depen-
dent and it is important to note that the retroperitoneum
is not specifically evaluated in the FAST scan which se-
verely limits the utility of FAST in the assessment for
renal trauma. While ultrasound may yield some vital
information in the hands of an experienced sonographer,
it remains inadequately sensitive for the detection of
traumatic renal injuries, with sensitivities reported as low
as 22% [17, 30]. Ultrasound cannot reliably detect or
characterize major vascular injures nor can it assess renal
function [17, 31]. US studies evaluating new ultrasound
technologies including 3D contrast-enhanced ultrasound
may better support the role of sonography in the
assessment of renal trauma in the future [32].
Magnetic resonance imaging (MRI)
MRI is not appropriate as an initial screening test in the
setting of acute trauma due to the length of time required
for imaging and the need to cooperate with breathhold-
ing and laying still which can be impossible for a trau-
matized patient. There can also be issues related to MRI
compatibility and safety of trauma resuscitation equip-
ment in the event that the patient becomes hemody-
namically unstable. However, since MRI does not use
ionizing radiation, it should be considered as an alter-
native to CT when follow-up imaging is needed to assess
for renal complications, particularly in pediatric patients
or in women of reproductive age.
Renal injuries: radiologic description
and staging
In an era of expectant (also referred to as nonoperative
or conservative) management of renal injuries, radiolo-
gists play a critical role in identifying renal injuries that
are more likely to require surgical intervention. The goals
for renal imaging for suspected trauma are to (1) accu-
rately stage the injury, (2) identify pre-existing renal
pathology in the injured kidney, (3) document that the
uninjured kidney is present and functional, and (4)
identify concomitant injuries to other abdominal organs
[29].
The description of renal injuries is most commonly
performed using the American Association for Surgery
in Trauma (AAST) renal grading system (Table 3,
Fig. 2) [33]. The AAST grading system provides a stan-
dard for classifying renal injuries and describes the
spectrum of injuries from least to most severe, with each
grade having incrementally more significant implications
for morbidity, mortality, and clinical management [34,
35]. The AAST grading scheme has been validated as a
measure of renal injury severity that predicts the need for
surgical intervention and has been shown to be predictive
for nephrectomy, dialysis, and death in blunt trauma and
for nephrectomy in penetrating trauma function [34, 36].
Among predictors for nephrectomy including penetrat-
ing injury, overall injury severity, hemodynamic insta-
bility, and transfusion requirements, the AAST organ
injury scale has been found to be the strongest risk factor
for nephrectomy [37, 38]. It is also inversely correlated
with renal function, with renal function decreasing as the
AAST grade increases [39].
Grade 1
Renal parenchymal contusions and nonexpanding sub-
capsular hematomas are classified as grade 1 renal in-
juries and represent approximately 75–85% of all renal
injuries. Contusions are rounded, hypoattenuating areas
of decreased enhancement (Fig. 3). They may be poorly
visualized or inapparent on the initial trauma scan (late
corticomedullary phase), but at times may be detected on
delayed excretory images as rounded areas of decreased
enhancement that may retain small amounts of residual
Table 3. AAST-OIS grading system for renal trauma
Grade Injuries
Abdominal imaging: special focus kidney: renal trauma
I Contusion
Hematoma: subcapsular, nonexpanding
II Hematoma: perirenal hematoma confined to
retroperitoneum, nonexpanding
Laceration: <1.0 cm cortical parenchymal depth without
urine leak
III Laceration: >1.0 cortical parenchymal laceration without
collecting system rupture or urine leak
IV Laceration: parenchymal laceration extending through
cortex, medulla and the collecting system
Vascular: Main renal artery or vein injury with
contained hemorrhage
V Completely shattered kidney
Avulsion of renal hilum which devascularizes kidney
Advance one grade for bilateral injuries for grades I–III
S. T. Chong et al.: Imaging evaluation and implications for clinical management

Fig. 2. A–E Illustrations of

AAST- OIS Grades 1–5
renal injuries. A Grade 1
Subcapsular hematoma and
contusion. B Grade 2
Superficial lacerations and
nonexpanding perinephric
hematoma. C Grade 3
Deeper lacerations without
collecting system injury. D
Grade 4 Complex
lacerations that involve the
parenchyma, vascular
structures, and collecting
system. E Grade 5
Completely shattered
kidney and hilar avulsion
injuries. Illustrations by
Carolyn Nowak.
 S. T. Chong et al.: Imaging evaluation and implications for clinical management

Fig. 3. AAST grade 1. A 65-year-old male drinking alcohol

while working on roof who fell approximately 20 feet. Subtle,
ill-defined area of decreased enhancement in the medial as-
pect of the left kidney, which is more apparent when com-
pared to the contralateral kidney, is consistent with a Fig. 4. AAST grade 1. Hyperdense subcapsular hematoma
contusion. Note the posterior pararenal hematoma related to along the left kidney conforms to the capsular margin and is
fractures in the overlying ribs. slightly convex along its medial margin where it exerts mass
effect and indents upon the renal parenchyma.
contrast [21]. Renal contusions are presumed to be pre-
sent when a patient with suspected renal trauma presents
with new hematuria without urinary tract abnormalities
on imaging studies. Subcapsular hematomas are hyper-
dense when acute (Hounsfield units >30–50 or isodense
and/or hyperdense relative to renal parenchyma) and
become hypodense when chronic (Fig. 4). They are
confined between the renal parenchyma and capsule
which results in a fluid collection that is typically
eccentrically located and crescentic or convex in mor-
phology but can become more lobular or even biconvex
with large subcapsular hematomas. The kidney margin
may be indented. Mass effect from the subcapsular he-
matoma may result in a delayed nephrogram . Deter-
mining whether the subcapsular hematoma is expanding
is impossible on a single-phase CT study and may be
difficult even if delayed phase images are obtained [21].
Longstanding compression of the renal kidney by a Fig. 5. An 18-year-old male football player with increasing
subcapsular hematoma can result in renin-mediated left flank pain and intermittent headaches, elevated blood
pressure, but no history of trauma. Hypodense fluid collection
hypertension, also known as Page kidney (Fig. 5).
in the left kidney is consistent with a chronic subcapsular
hematoma that causes significant compression of the left
Grade 2 kidney. It was suspected that the hematoma was the result of
blunt force impact during the football season that went
Perirenal hematomas that are not expanding and con- unnoticed by the patient. The hematoma was drained and the
fined to the retroperitoneum and lacerations that mea- patient’s hypertension resolved over time.
sure <1.0 cm in cortical parenchymal depth comprise
grade II injuries. There should be no evidence of urine perinephric hematomas are therefore streaky, diffuse
leak. Perirenal hematomas are usually the result of lac- and/or ill-defined in morphology without distortion of
erations and are hyperdense fluid collections that are not the renal contour [21, 40]. Large perirenal hematomas
bounded by the renal capsule and dissect into the per- can exert mass effect by displacing the kidney anteriorly
inephric fat and bridging septae within Gerota’s fascia; and compressing the adjacent colon. They may extend
S. T. Chong et al.: Imaging evaluation and implications for clinical management
Fig. 6. AAST grade 2. A 29-year-old male with stab wound
through right flank. Superficial lacerations graze the surface of
the right kidney (arrow). The right subcutaneous emphysema
localizes the entry site for the knife (white arrowheads). A
linear, hypodense liver laceration is apparent along the tra-
jectory of the knife wound (black arrowheads).
toward the aorta or cross the midline into the con-
tralateral retroperitoneal space [16, 40]. Superficial lac-
erations are typically linear, jagged, or cleft-like areas of
decreased or absent enhancement in the renal par-
enchyma (Fig. 6). They may be difficult to distinguish
from segmental or subsegmental infarcts, which can be
similar in imaging appearance.
Grade 3
Larger lacerations that measure >1.0 cm in length are in
this category. Grade III lacerations may involve the
cortex and/or medulla but not the collecting system;
therefore, there should be no evidence of urine leak
(Fig. 7). As lacerations increase in size, the imaging
appearance becomes more varied and complex. Lacera-
Fig. 7. AAST grade 3. A 24-year-old male who hit a tree,
with notable excursion into the vehicle and required prolonged
extrication. Linear laceration in the anterior right kidney ap-
pears to extend full thickness through the parenchyma to the
collecting system (A) but there was no urine extravasation on
the delayed images (B).
tions are usually easily differentiated from renal cysts,
which are typically rounded, smoothly marginated and
measure similar or equal to fluid attenuation, and from
scars, which also have smooth contours and generally
involve the margin with some parenchymal volume loss
[21].
Grade 4
Grade IV injuries are comprised of lacerations that are
deeper and more extensive, involving the cortex, medulla,
and collecting system as well as renal vascular injuries in
which the hemorrhage is contained (Figs. 8, 9, 10). There
should be evidence of contrast opacified urine leaking
into the perirenal space, which may require excretory
phase CT images for confirmation. A large enough
perirenal hematoma may tamponade a urine leak,
resulting in a false-negative result, and may require re-
peat imaging in order to detect. At times, it is possible
 S. T. Chong et al.: Imaging evaluation and implications for clinical management
Fig. 8. AAST grade 4. Adult male stabbed in the left flank
region. There is a large left perinephric hematoma (arrows)
with hemorrhage in the left paracolic gutter and posterior
pararenal space. Ill-defined lacerations involve the full thick-
ness of the anterior interpolar cortex and extend to the col-
lecting system (A, B). A large hematoma in the bladder lends
further evidence for collecting system injury (arrowheads) (C).
that urinary extravasation is identified without an
apparent parenchymal laceration. Isolated urinary
extravasation is not an indication for surgical explo-
ration, as the majority of urinary leaks resolve sponta-
neously. However, as many as 37% of cases may require
endoscopic ureteral stent placement [41, 42]. Injuries to
the main renal artery and vein include laceration, dis-
section, and thrombosis. They may also result in seg-
mental infarcts, with the size of the infarct directly
related to the size of the injured vessel [17].
Grade 5
The completely shattered kidney and avulsion of the
renal hilum represent the most severe of renal injuries
and result in devascularization of the kidney (Fig. 11).
The completely shattered kidney demonstrates extensive
lacerations involving the parenchyma and collecting
system that separate the kidney into multiple fragments.
Renal hilar injuries occur in 5% of all renal traumas and
are often associated with multi-organ injuries [16].
Avulsion of the renal hilum results in injuries to the UPJ
as well as the main renal artery and vein. There may be
complete or partial avulsion of the UPJ. In complete
UPJ avulsion, there is notable absence of excreted con-
trast in the ureter despite opacification of the intrarenal
collecting system. In partial UPJ avulsion, there may still
be contrast opacification of the ureter. The most com-
mon injury to the renal vascular pedicle is renal artery
occlusion, which is caused by marked stretching of the
artery leading to dissection and thrombosis [16]. Promi-
nent areas of segmental parenchymal devascularization
or global absence of enhancement may be present, with
preservation of the reniform contour. Renal infarction
usually results [21, 43]. The cortical rim sign due to col-
lateral enhancement of the renal capsule that has been
observed in global renal infarction is seldom seen in the
initial scan as it requires at least 8 hours to develop [44].
If there are multiple injuries to the same organ or
bilateral injuries, the AAST grade should be advanced
one grade.
Injuries not addressed by the AAST
grading scale and proposed revisions
Extraluminal contrast extravasation and contained vas-
cular lesions such as pseudoaneurysm and arteriovenous
fistulae (AVF) are not specified in the AAST grading
scale as they are injuries identified by CT imaging,
whereas the AAST grading scale was based on findings at
the time of surgery and created well before the common
use of CT scanners. Extraluminal contrast extravasation
represents active hemorrhage and appears as ill-defined
areas of high attenuation that are similar to that of aortic
attenuation on contrast-enhanced CT studies. Contained
vascular lesions are also similar in attenuation to the
enhanced aorta but on delayed images remain similar in
size and morphology, and decrease in attenuation,
‘‘washing out’’ similar to the aorta. In contrast, active
bleeding tends to increase in size and retain a higher
attenuation than the aorta on delayed imaging [45].
Contrast extravasation may require angioembolization
S. T. Chong et al.: Imaging evaluation and implications for clinical management
Fig. 9. AAST grade 4. A 42-year-old male hit in the right flank
by a tree branch. Axial (A) and sagittal (B) images through the
right kidney demonstrate deep lacerations involving the right
kidney, with prominent areas of active bleeding (arrow). There
to control bleeding and decrease likelihood for
nephrectomy and indicates the need for surgical inter-
vention [46].
In addition to active bleeding and contained vascular
lesions, CT may also demonstrate segmental vascular
injuries which manifest as areas of decreased enhance-
ment or nonenhancement of the parenchyma. They are
usually triangular in shape and most commonly due to
segmental arterial or venous tears or thrombosis
(Fig. 12) [21]. It has been proposed that these be added
as grade IV injuries [35] but this remains debated in the
literature as they tend to be less severe injuries that are
associated with lower operative intervention compared
to other grade IV injuries such as collecting system lac-
erations [47]. The overwhelming number of patients with
segmental infarcts can be managed successfully with
observation only, whereas more than half of grade IV
collecting system lacerations require intervention [47].
Although these injuries should be addressed by the
AAST staging system, their inclusion has been recom-
mended into a lower injury classification to avoid
decreasing the prognostic value of the grading system
[47].
Several CT findings have been shown to be predictive
for requiring surgical intervention to control hemorrhage
from renal injuries. These ‘‘high risk’’ CT findings are
contrast extravasation, complex lacerations, and per-
inephric hematoma size. The total number of these high
risk CT findings has been shown to be directly correlated
with the need for intervention, with up to 67% increased
risk or 122-fold increased odds for intervention when all
three CT findings are present [48–51]. It has been pro-
posed that these findings form the basis for a radiological
is a large amount of perinephric hematoma that extends beyond
Gerota’s fascia into the paranephric space. The patient was
hemodynamically stable and managed conservatively, with
complete healing of the right kidney.
risk score and that the AAST grading be modified to
reflect the management implications of the radiologic
risk score by substratifying Grade IV injuries into grades
IVa and IVb, representing lower and higher risk groups,
respectively [48–51].
Other proposed revisions to the AAST grading scale
include downgrading shattered kidneys to grade IV
classification and including any laceration to the col-
lecting system including UPJ disruption as grade IV in-
juries, as well as expanding grade V injuries to include
main renal artery or vein laceration, avulsion, and
thrombosis [35, 47].
Management considerations and role
of interventional radiology
Prior to advanced imaging techniques, many renal in-
juries required surgical exploration. Over the past two
decades, due to improvements in trauma surgical care,
refinements in CT technology that have allowed radiol-
ogists to provide improved staging of renal injuries, and
advancements in interventional radiology capabilities,
the urologic trends have shifted to conservative man-
agement such that expectant management has become
the prevailing standard for the treatment of the majority
of renal injuries [2, 31, 37]. The ultimate goals of con-
servative management are to minimize negative explo-
rations and unnecessary repairs, avoid unnecessary
nephrectomy, increase the rates of renal salvage, and
avoid long-term complications such as dialysis [2, 31].
The majority of renal injuries are grades I–III (85%) and
most of these are managed nonoperatively with success
[20]. For the highest grade renal injuries (grades IV and
 S. T. Chong et al.: Imaging evaluation and implications for clinical management
Fig. 10. AAST grade 4. Adult male involved in high speed
motor vehicle collision. There are lacerations and segmental
areas of devascularization in the left kidney. A large per-
inephric hematoma displaces the kidney anteriorly and cre-
ates mass effect on the adjacent structures (arrowheads).
Delayed images demonstrated irregularities along the col-
lecting system margins consistent with lacerations. Frank
urinary extravasation was present more inferiorly (not shown).
V), a course of expectant therapy may be trialed suc-
cessfully in hemodynamically stable patients [52]. Even
for penetrating renal injuries, for which immediate
nephrectomy was considered mandatory in the past, a
subset of these injuries may be managed nonoperatively
[53]. In pediatric patients, it is interesting to note that
nephrectomy rates are three times higher when pediatric
renal injuries are treated at adult hospitals [6].
Role of angiography and embolization
Angiography and embolization are essential adjuncts for
the successful nonoperative management of renal in-
juries. Superselective embolization can increase the
chances of renal salvage and preservation of tissue and
function [54]. Angiography is appropriately indicated
when contrast-enhanced CT demonstrates contrast
extravasation or a contained vascular lesion (Figs. 13,
14). Contrast extravasation and increased size (diameter
greater than 4 cm) and extent of perinephric hematoma
were found to be significant predictors for needing
angioembolization [55, 56]. In a review of over 500 pa-
tients in the U.S. National Trauma Data Bank, the use of
angiography and angioembolization eliminated the need
for nephrectomy in 78% and 83% of grade IV and grade
V injuries, respectively, although most required repeat
angiography to successfully control bleeding [31, 46].
Angiography with angioembolization is not fail-safe
however. One series from a leading urban trauma center
demonstrated a failure rate of 27% and those who failed
angiography regardless of angioembolization required
significantly more blood transfusions [31, 57].
Complications of renal injuries
Early complications occur within one month of injury
and include urinoma, delayed bleeding, urinary fistula,
infection, abscess, pseudoaneurysm, persistent hema-
turia, and hypertension [15, 58]. Late complications in-
clude hydronephrosis, arteriovenous fistula (AVF),
pyelonephritis, calculus formation, and delayed hyper-
tension. Chronic hypertension from renal trauma is rare
[15]. While low-grade injuries can heal completely,
higher-grade injuries often result in permanent
parenchymal scarring [59]. Scarring that occurs near the
renal pelvis or ureter may result in mechanical obstruc-
tion leading to urinary stasis with subsequent stone for-
mation and infections [15].
Recommendations for follow-up
imaging
Historically, follow-up imaging was recommended
within 48 hours to identify progression of renal injuries
or complications of conservative management [60]. Sev-
eral studies have demonstrated that the diagnostic yield
of routine follow-up imaging is very low and that for
grades I–III injuries and grade IV injuries without urine
extravasation, routine re-imaging is unnecessary [60–63].
The vast majority (96%) of urine leaks in high grade
renal injuries can be detected with delayed excretory
phase imaging, and the incidence of missed or delayed
diagnosis of urinary leak in patients with high grade re-
nal injuries and excretory phase images on the admission
CT study is extremely low (0.2%) [63]. Routine follow-up
imaging is not recommended in grades I–III and in grade
IV without urine leak [62, 63]. Selective re-imaging
should be considered in grade IV injuries with urine leak
and grade V injuries, guided by clinical and laboratory
variables, including flank pain, hematocrit drop, leuko-
cytosis, and fever, which have been found to be more
predictive for the need for re-imaging [62, 64].
In pediatric patients, follow-up imaging may be per-
formed with ultrasound [26, 65]. If ultrasound findings
are equivocal and/or additional cross-sectional imaging
is required, MRI should be used instead of CT when
S. T. Chong et al.: Imaging evaluation and implications for clinical management
Fig. 11. AAST grade 5. A 29-year-old male with gunshot
wound to the right abdomen. The right kidney demonstrates
extensive lacerations and areas of devascularization (white
arrows) with residual amounts of enhancing parenchyma
(black arrows). The renal hilum is markedly irregular with
Fig. 12. A 42-year-old female kicked by a horse. Geographic, wedge-shaped hypodense areas in both kidneys, left greater
than right, are consistent with segmental infarcts.
possible in order to minimize exposure to ionizing radi-
ation (Fig. 15) [25, 65]. Grade V injuries may result in
functional loss related to parenchymal scarring and
volume loss and may require longer-term follow-up [66].
Summary
Most renal injuries are mild in severity and successfully
managed conservatively. Severe renal injuries are usually
associated with multisystem injuries, may require inter-
ventional radiology to control hemorrhage and improve
significant narrowing of the renal hilar vessels. Small blu-
shes of active bleeding are present in the posterior per-
inephric space (black arrowhead). A large amount of
hemorrhage is present along the retroperitoneum (white
arrowheads).
the chances for renal salvage, and are more likely to fail
nonoperative management. CT with intravenous con-
trast is the imaging test of choice to assess for renal in-
juries. Delayed excretory imaging is recommended when
collecting system injury is suspected. Radiologists play a
critical role in identifying renal injuries that are more
likely to require surgical intervention and should make
every effort to describe renal injuries according to the
AAST grading scheme to better inform the surgeon’s
management decisions. The AAST classification is the
S. T. Chong et al.: Imaging evaluation and implications for clinical management

bFig. 13. Iatrogenic trauma. A Brisk active bleeding (black

arrowheads) emanates from the anterior left kidney in a pa-
tient who returned for worsening flank pain following biopsy
for suspected renal cell carcinoma. A large perinephric he-
matoma is present. B Digital subtraction angiography
demonstrates a prominent area of active bleeding (white ar-
row). C Following angioembolization with coils, there was no
evidence of active bleeding but a new large area of devas-
cularization of the interpolar cortex is evident.

Fig. 14. A 26-year-old male struck by a train. The right

kidney is extensively lacerated, with few areas of remaining
parenchyma (white arrowheads) in the upper pole while the
remainder of the kidney is completely devascularized. Arterial
phase image shows abrupt termination of the right renal ar-
tery (white arrow). Angiography demonstrated right renal ar-
tery dissection. A covered stent was placed, and the patient
recovered without surgical intervention. Extensive emphy-
sema is present along the right body wall.

most widely used system to describe renal injuries, with

management and prognostic implications that are
applicable to both adult and pediatric populations.
Contrast extravasation, indicating active bleeding, is not
explicitly addressed by the AAST system and should be
mentioned as its presence is predictive for the failure of
nonoperative management.
S. T. Chong et al.: Imaging evaluation and implications for clinical management

bFig. 15. A 12-year-old male who fell onto right flank from
approximately 4 feet height, with frank blood in urine.
Nephrographic phase image demonstrates a wide laceration
through the right interpolar cortex with obvious extravasation
of excreted contrast material into the retroperitoneum. Follow-
up imaging with magnetic resonance urography (MRU)
demonstrates dilatation of the upper pole calyces secondary
to infundibular stenosis from scarring.

Acknowledgments. The authors would like to thank Alexis Boscak,

MD, Department of Radiology, University of Maryland Shock Trauma
Center, Baltimore, Maryland, and Zarina Lockhat, MD, FFRAD (D)
SA, Department of Radiology, University of Pretoria, Pretoria, South
Africa for contributing the cases of penetrating renal injuries.

Compliance with ethical standards

Conflict of interest None of the authors have any conflicts of interest

to disclose.

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