Faculty Collaboration Database

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 Oct;148(10):924-31

Date

08/16/2013

Pubmed ID

23945834

DOI

10.1001/jamasurg.2013.2747

Scopus ID

2-s2.0-84886439807 (requires institutional sign-in at Scopus site)   90 Citations

Abstract

IMPORTANCE: Severe renal injuries after blunt trauma cause diagnostic and therapeutic challenges for the treating clinicians. The need for an operative vs a nonoperative approach is debated.

OBJECTIVE: To determine the rate, causes, predictors, and consequences of failure of nonoperative management (NOM) in grade IV and grade V blunt renal injuries (BRIs).

DESIGN: Retrospective case series.

SETTING: Twelve level I and II trauma centers in New England.

PARTICIPANTS: A total of 206 adult patients with a grade IV or V BRI who were admitted between January 1, 2000, and December 31, 2011.

MAIN OUTCOMES AND MEASURES: Failure of NOM, defined as the need for a delayed operation or death due to renal-related complications during NOM.

RESULTS: Of 206 patients, 52 (25.2%) were operated on immediately, and 154 (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%) and was related to kidney injury in 10 (6.5%). None of these 10 patients had complications because of the delay in BRI management. The mean (SD) time from admission to failure was 17.6 (27.4) hours (median time, 7.5 hours; range, 4.5-102 hours), and the cause was hemodynamic instability in 10 of the 12 patients (83.3%). Multivariate analysis identified 2 independent predictors of NOM failure: older than 55 years of age and a road traffic crash as the mechanism of injury. When both risk factors were present, NOM failure occurred for 27.3% of the patients; when both were absent, there were no NOM failures. Of the 142 patients successfully managed nonoperatively, 46 (32.4%) developed renal-related complications, including hematuria (24 patients), urinoma (15 patients), urinary tract infection (8 patients), renal failure (7 patients), and abscess (2 patients). These patients were managed successfully with no loss of renal units (ie, kidneys). The renal salvage rate was 76.2% for the entire population and 90.3% among patients selected for NOM.

CONCLUSIONS AND RELEVANCE: Hemodynamically stable patients with a grade IV or V BRI were safely managed nonoperatively. Nonoperative management failed for only 6.5% of patients owing to renal-related injuries, and three-fourths of the entire population retained their kidneys.

Author List

van der Wilden GM, Velmahos GC, Joseph DK, Jacobs L, Debusk MG, Adams CA, Gross R, Burkott B, Agarwal S, Maung AA, Johnson DC, Gates J, Kelly E, Michaud Y, Charash WE, Winchell RJ, Desjardins SE, Rosenblatt MS, Gupta S, Gaeta M, Chang Y, de Moya MA

Author

Marc Anthony De Moya MD Chief, Professor in the Surgery department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Adolescent
Adult
Aged
Aged, 80 and over
Female
Hospital Mortality
Humans
Kidney
Length of Stay
Male
Middle Aged
Multiple Trauma
New England
Retrospective Studies
Salvage Therapy
Time Factors
Trauma Centers
Trauma Severity Indices
Treatment Outcome
Wounds, Nonpenetrating