Case report and review of the literature

CONSERVATIVE MANAGEMENT OF MAJOR BLUNT RENAL TRAUMA IN A

CHILD: IS IT A SAFE THERAPEUTIC MODALITY? CASE REPORT AND REVIEW
OF THE LITERATURE
Zlatan Zvizdi*1, Emir Milii1, Carmen Dedi1, Amra Dananovi2 Lejla Milii2.
1

Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Bolnika 25, 71000
Sarajevo, Bosnia and Herzegovina
2

Clinic of Radiology, Clinical Center University of Sarajevo, Bolnika 25, 71000 Sarajevo,
Bosnia and Herzegovina
* Corresponding author
ABSTRACT
Renal parenchymal injuries can lead to significant morbidity and mortality, but there is still no
consensus about the optimal treatment of the high-grade renal injuries. Hundreds of papers
about the modalities of treatment of renal injuries have been published in medical literature,
but there remains a regional and individual differences in the treatment of children and adults
with high-grade kidney injury, which impedes the establishment of a unified algorithmic
treatment. The aim of this study was to contribute to the knowledge that nonoperative
management strategy can be safely chosen in children with severe blunt renal injuries who
were hemodynamically stable, as the preliminary step or as the definitive treatment.
Key words: Blunt renal trauma, nonoperative management, children
INTRODUCTION
Kidney injuries occur in approximately 10% of all blunt abdominal trauma cases [1]. Blunt
trauma is the most common type of the injury of the kidney and represent 82%-95% of all
renal trauma [2]. CT scan has proved to be an effective means of staging renal trauma [ 3].
Based on severity, renal injuries were divided in five grades using the classification of the
organic injuries survey committee from the American Association of Surgery in Trauma
(AAST) [4]. (Table 1)
Table 1. Organ Injury Scale for kidney
AAST Classification
Grade
I
II
III
IV

Findings
Parenchymal contusions and isolated subcapsular hematomas
Superficial cortical lacerations less than 1 cm in depth and nonexpanding
perirenal hematomas
Lacerations greater than 1 cm in depth without extension into the collecting
system or evidence of urinary extravasation
Deep lacerations that involve the collecting system, traumatic thrombosis of a
segmental renal arterial branch, and injuries to the main renal artery not
associated with renal devascularization
Shattering of the kidney into multiple fragments and devascularizing injuries to
the renal pedicle, avulsion of the renal artery, as well as in situ thrombosis of an
intact renal artery

Informations from ref. 4.

Blunt renal trauma may be classified as minor or major [ 4]. More than three quarters of cases
of renal trauma (75-85%) are classified as minor and majority of them is treated
conservatively. High-grade renal injuries comprise the remaining 15% of cases with grade V
injuries representing only 5% of blunt renal injuries [ 4]. The reported incidence of high-grade
renal injuries is 1%-2% of all traumas [ 5]. The conservative management of grade III to IV
renal injuries in the setting of blunt trauma has been well established, the treatment of grade V
injury remains a subject of debate. In the past, grade V injuries treated surgically, while recent
papers suggest that this grade can be treated conservatively in hemodynamically stable
patients. We report a case of a grade III renal injury with a large perinephritic hematoma in a
7-year boy managed successfully with conservative measures.
CASE REPORT
A 7 year-old boy who sustained blunt abdominal trauma following fall on the stair, presented
to emergency room of University Clinical Center Sarajevo with complaints of lower left
abdominal pain and left back pain since the time of injury. No history of hematuria. The
physical examination revealed marked tenderness present in the left lower abdomen and the
left lumbar region. The patient was hemodynamically stable (systolic blood pressure > 90 mm
Hg, puls 96 per minute). Serum haemoglobin was 110 g/L. Urine analysis showed
microscopic haematuria (40-50 RBCs). At admission ultrasonograpy of abdomen showed
features suggestive of left renal injury. Computerized Tomography (CT) of the abdomen and
pelvis with intravenous contrast demonstrated deep parenchymal laceration 2.1 cm in depth
with active bleeding and a large perinephritic hematoma (Figure 1.).

Figure 1. Initial sagittal CT scan showing deep parenchymal laceration 2,1 cm in depth (white arrow) with a
large perinephritic hematoma (black arrows).

Three dimensional reconstruction of contrast CT showed left kidney laceration without

contrast extravasation (Figure 2.).

Figure 2. Three dimensional reconstruction of contrast sagittal CT showing left kidney laceration without
contrast extravasation

Base on the American Association for the Surgery of Trauma organ injury scale [4], the renal
injury was compatible with a grade III injury. The opposite kidney was normal. Becase of the
patient's hemodynamic stability, the boy was admitted to the pediatric surgery ward and
treated conservatively with controlled fluid resuscitation, bed rest, frequent serum
haemoglobin monitoring, IV antibiotics and analgesics. On day 3 repeated abdominal and
pelvis CT scan showed no previously reported active bleeding with the persistence of
laceration of the left kidney and perinephritic hematoma.

Figure 3. Sagittal computerized tomography after 72 h showing no evidence of the left perinephritic expanding
hematoma (black arrows) and no evidence of active bleeding.

On the day 5 the the tenderness of the left lower abdomen and the left lumbar region
decreased significantly. Urine analysis showed no evidence of microscopic hematuria.
Abdominal ultrasonography on day 7 showed substantial resolution of the mass with residual
reduced perinephritic hematoma. CT scan done on day 11 showed near complete resolving of
renal laceration and perinephritic hematoma.

Figure 4. Sagittal computerized tomography on the day 11 showing a significant regresion of perinephritic
hematoma (white arrows) with advanced healing of parenchymal laceration

All the time, vitals, hemoglobin level and serum electrolytes were normal. Patient was
discharged on day 12 with oral antibiotics for 7 days. On follow up at 1, 3 and 6 month child
was normotensive and ultrasonography findings were normal.
DISCUSSION
Due to differences in anatomy and physiology, as well as the higher incidence of pre-existing
renal disease, children are more prone to renal injury than adults. Children's kidney is placed
lower in the abdomen, more mobile, less protected by the lower ribs and the muscles of the
abdomen and flank and perirenal fat is less developed. Also, the kidney of a child is
proportionately larger than the adult kidney. Preservation of the kidney either by conservative
treatment or operative reconstruction is an essential part of management of blunt renal injury.
The decrease of surgical interventions in the recent years reflected better understanding of the
natural history of blunt renal trauma [6]. The current indications for surgical exploration in
children with blunt renal trauma and major renal lacerations (grades III-V) include a changing
abdominal examination suggestive of a major intra-abdominal injury, persistent lifethreatening bleeding with hemodynamic instability, expanding or pulsatile retroperitoneal
hematoma, inability to stop persistent or delayed hemorrhage via selective vascular
embolization and accompanying extraabdominal or intraabdominal lesions [7]. On the other
hand, recent publications showed successful conservative treatment of high-grade renal
injuries associated with high grade intraabdominal solid organs injuries [8]. However, a
significant number of high grade renal injuries in children will heal with no intervention [1,9].
In fact, pilot study by Santucci et al [9] evaluated 2 047 blunt renal traumas and concluded
that more than 75% high grade renal blunt trauma needed surgical interventions. The rate of
surgical management of high grade renal injury due to blunt traumas had gradually decreased
to 35% in 2010 [5]. The decrease of surgical interventions reflected better understanding of
the natural history of blunt renal trauma. The safety of nonoperative treatment of major renal
injuries in children has been confirmed by several studies [ 10,11,12]. Fitzerald et al. instituted a
conservative management protocol for blunt renal trauma in pediatric patients and suggested
that nearly 80% of pediatric patients with high-grade blunt renal trauma were able to be
management expectantly [13]. They used conservative approach in cases that were
hemodynamically stable or had a favorable response with up to 2 units of blood transfused
and no operative renal lesion on imaging [13]. Although hematuria is a common sign of renal
trauma, being present in 8094% of cases [14], the decision for renal imaging in diagnosing

and grading the renal injuries should not be based on urine analysis solely. Numerous studies
have shown that there was no absolute correlation between the presence, absence or degree of
hematuria and the severity of the renal injury [14,15,16]. The patients clinical status, history,
and injury mechanism should also be considered. In our case, microscopic hematuria (<50 red
blood cells per high-powered field) is no correlated with the severity of renal injury.
Therefore, we believe that the ideal diagnostic methodology in the cases of blunt abdominal
trauma would be performing abdominal/pelvic CT and urinalysis on all children who
presented with blunt abdominal trauma. In fact, abdominal/pelvic CT scanning is the most
accurate screening test for high-grade renal injuries in children since the rate of diagnosis of
blunt renal trauma by computed tomographic is 100% [17]. Other diagnostic methods have the
lower diagnostic rate, so that the ultrasonography has the diagnosis rate of 91% and
intravenous pyelography (IVP) of 82% [17].
CONCLUSION
Based on our experience with this case and the cases presented in recent medical literature,
we think that conservative management of III-IV grade renal hemodynamically stable injuries
is appropriate in the management of renal trauma. We believe that conservative treatment
reduces the number of emergency operations and the numbers of unnecessary nephrectomies
as well as the rate of early and late postoperative complications. Certainly, each case must be
individually analyzed and a decision on the type of treatment should be made on the basis of
the mechanism of injury, radiological findings and the patient's hemodynamic stability.
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Address:
Zlatan Zvizdi, Pediatric Surgeon MD. MSc
Clinic of Pediatric Surgery
Clinical Center University of Sarajevo
Bolnika 25, 71000 Sarajevo
Bosnia and Herzegovina
Phone: ++387 33 297 144
zlatanzvizdic@yahoo.com