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The conservative management of renal trauma:

a literature review and practical clinical


guideline from Australia and New Zealand
Steve P. McCombie*, Isaac Thyer, Niall M. Corcoran, Christopher Rowling,
John Dyer, Anton Le Roux**, Melvyn Kuan, D. Michael A. Wallace and
Dickon Hayne*
*School of Surgery, University of Western Australia, Crawley, Departments of Urology, Infectious Diseases, **Radiology,
Fremantle Hospital, Fremantle, Department of Urology, Sir Charles Gairdner Hospital, Nedlands, WA, and Departments
of Urology and Surgery, Royal Melbourne Hospital and University of Melbourne, Parkville, VIC, Australia

Objective Association for the Surgery of Trauma (AAST) kidney


To review the literature and make practical injury severity scale.
recommendations regarding the conservative management Graded recommendations are made regarding several key
of renal trauma. topics including: imaging, inpatient management,
antibiotics, return to activity, and follow-up.
Patients and Methods Grade IV injuries and intraoperative consults are examined
Relevant articles and guidelines published between 1980 and separately in view of the diculties these groups cause in
2014 were reviewed. making appropriate treatment decisions.
Graded recommendations were constructed by a
multi-disciplinary panel consisting of urologists,
radiologists, and infectious disease physicians. Conclusion
These recommendations underwent formal review and
A practical clinical guideline is provided regarding the
debate at the Western Australian USANZ 2013 state
conservative management of renal trauma.
conference, and were presented at the USANZ 2014 annual
scientic meeting.

Results Keywords
The literature on the conservative management of renal renal trauma, non-operative management, review, guideline,
trauma is reviewed within the framework of the American diagnostic imaging, follow-up

Introduction ureteric stenting, percutaneous drainage, and embolisation


within a conservative approach has increased the range of
The conservative management of blunt renal trauma was rst
injuries to which conservative management can be applied
proposed in the 1940s [1]. Since then the benets of this
[1,4,5,8,10].
approach have become increasingly apparent with reductions in
nephrectomy rate, complications, and hospital stay all being However, while several studies have shown a conservative
reported [13]. This has resulted in a paradigm shift towards approach to be successful, very few have addressed what
managing increasingly severe blunt renal trauma with a specically this conservative approach should entail. The
conservative approach [1,49]. The selective application of this EAU [4], AUA [9], and Socit Internationale dUrologie
approach to penetrating renal injuries has also been gaining International Consultation on Urological Diseases renal
momentum since this was rst recommended in the 1980s trauma subcommittee (renal trauma subcommittee) [5] have
[1,4,5,8,10]. This evolution in the management of renal trauma provided some recommendations; however, there remains
has been made possible by advances in both imaging and a hiatus on specic guidance about certain aspects of
minimally invasive techniques [1,4,5,8,10]. The widespread conservative management. As such there seems to be a wide
availability of CT allows clinicians to be much more informed variation in practice regarding issues such as repeat imaging,
about the injuries they are treating, while the ability to use inpatient monitoring, thromboprophylaxis, antibiotics,

2014 The Authors


BJU International 2014 BJU International | doi:10.1111/bju.12902 BJU Int 2014; 114, Supplement 1, 1321
Published by John Wiley & Sons Ltd. www.bjui.org wileyonlinelibrary.com
McCombie et al.

Table 1 The American Association for the Surgery of Trauma (AAST)


kidney injury severity scale [11].
Results
Treatment Selection
Grade* Type Description
While increasing numbers of patients are being managed
I Contusion Normal imaging, non-visible or visible haematuria present
conservatively for renal trauma, criteria for identifying patients
Haematoma Non-expanding subcapsular haematoma with no
parenchymal lacerations who are suitable for this approach remains controversial
II Haematoma Non-expanding peri-renal haematoma conned to [4,5,9,14]. Some appear to base treatment decisions largely on
retroperitoneum
injury grade or radiological ndings [13], whereas others
Laceration Cortical laceration <1 cm without urinary extravasation
III Laceration Cortical laceration >1 cm without urinary extravasation appear to rely more heavily on assessment of the patients
IV Laceration (a) Laceration through corticomedullary junction into clinical status [14]. Nonetheless, absolute contraindications for
collecting system
initiation of conservative management include life-threatening
Vascular (b) Renal artery or vein injury with contained
haemorrhage, or partial vessel laceration, or bleeding, renal pedicle avulsion, and the presence of a large,
vessel thrombosis expanding, pulsatile haematoma [4,5,8]. However, debate
V Laceration (a) Completely shattered kidney
surrounds other relative indications for intervention such as
Vascular (b) Avulsion of renal hilum with devascularised kidney
penetrating injury, high-grade injury, renovascular injury,
*Advance one grade for bilateral injuries up to grade III. non-pulsatile retroperitoneal haematoma, devitalised
segments, urinary extravasation, and injuries to other organs
[35,8,9]. Additionally, the threshold for intervention may be
lower in cases of a solitary functioning kidney or bilateral
discharge criteria, advice on activity restriction, and injuries [3]. The recently released AUA guideline recommends
follow-up. initiation of conservative management in all patients as long
as they are haemodynamically stable [9].

Methods Grade V injuries [14,15] and the need for platelet transfusion
[14], which reects activation of a massive transfusion
A literature search was conducted utilising MedLine, Embase,
protocol, have been identied as good predictors of the
and AustHealth; articles published between 1980 and 2012 were
need for intervention. Additionally, nomograms have been
included. Search terms used included: renal trauma, kidney
developed that are able to predict the need for renal
injuries, complications, bed rest, discharge criteria, follow-up,
exploration with >95% accuracy [16,17]. One such nomogram
and aftercare. Recommendations were then constructed by a
incorporates a combination of radiological (injury grade),
multi-disciplinary panel of experienced clinicians, based on the
serological (admission haemoglobin, blood urea nitrogen), and
available literature and their collective experience. The panel
clinical variables (heart rate, platelet transfusion within 24 h),
included urologists, radiologists, and infectious disease
and is even able to predict the need for renal exploration in
physicians. These recommendations were then modied after a
the context of a unit that oers embolisation as an alternative
formal review and debate at the Western Australian USANZ
to surgery [17].
2013 state conference, and were subsequently presented at the
USANZ 2014 annual scientic meeting. Grade IV Injuries
This guideline is designed for patients who remain stable, Whereas low-grade injuries rarely require intervention
without developing complications, on conservative and grade V injuries usually require exploration, the
management. The management of patients who require initial management of patients with grade IV injuries can be
or delayed intervention has been described extensively particularly challenging [18]. Not only does a dicult
elsewhere [25,11]. The American Association for the Surgery decision need to be made between renal exploration and
of Trauma (AAST) kidney injury severity scale [12] is used to conservative management, but the use and timing of other
classify renal trauma (Table 1) [11]; this scale has been both interventions, e.g. ureteric stenting, percutaneous drainage,
validated [13] and widely accepted [4,5,9]. Recommendations and embolisation, must also be considered. In one study,
are graded according to the EAU grading scale [4], which even when grade IV injuries were initially managed
closely resembles the grading scale used by the AUA [9]: non-operatively 11% of patients ultimately required renal
A. Based on clinical studies of good quality and consistency exploration, 27% required ureteric stenting, and 25%
addressing the specic recommendations and including at required embolisation [19].
least one randomised trial Decision-making for these injuries can be approached in a
B. Based on well-conducted clinical studies, but without sequential manner. Firstly, it must be determined if the patient
randomised clinical trials requires intervention to control bleeding; if they do then
C. Made despite the absence of directly applicable clinical embolisation appears preferable to renal exploration if it is
studies of good quality immediately available and the patient is stable enough for this

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Conservative management of renal trauma

[5,9]. While it is obvious that a haemodynamically unstable destabilising the patient and unnecessary nephrectomy [18].
patient requires intervention to control bleeding, serious Finally, while some of the renal injuries encountered at
consideration must also be given to intervening early in laparotomy may ordinarily be amenable to embolisation,
patients who are haemodynamically stable but at high-risk of the delay involved with organising this in theatre may be
ongoing blood loss. These patients appear to include those unjustied.
with a penetrating injury, and those with particular ndings
on CT (extravasation of intravascular contrast, medial
Initial Imaging
laceration, peri-renal haematoma with a diameter of >3.5 cm)
[9,18,20]. Next it must be determined if the patient requires Four-phase CT of the abdomen and pelvis with non-contrast,
intervention for urine leak; this may be in the form of ureteric arterial-, nephrographic-, and pyelographic-phased images is
stenting or renal exploration depending on the circumstances generally considered the gold standard initial imaging method
[9]. The AUA recommend that this is only required if injury to in renal trauma [46,9,11,21,23]. The American College of
the renal pelvis or ureter is suspected based on the presence of Radiology has made useful recommendations as to when other
a large medial urinoma, or urinary extravasation associated imaging methods may be appropriate [21]; importantly, in the
with an absence of contrast in the distal ureter [9]. If the event wherein CT is unavailable then combined assessment
patient does not require immediate intervention for bleeding with IVU and focused abdominal sonography for trauma
or urine leak then conservative management can be initiated, (FAST) is considered acceptable [21]. There appears to be a
although the need for delayed intervention should be regularly reasonable consensus in the literature that suitable criteria for
reviewed. The indication for delayed embolisation or initial imaging in adults are: visible haematuria, non-visible
exploration is evidence of ongoing bleeding (haemodynamic haematuria with shock, penetrating injury, signicant
instability, falling haemoglobin, ongoing transfusion associated injuries, and high-risk injury mechanisms
requirements). The indications for delayed intervention for [4,5,9,21].
urine leak are sepsis, pain, increasing urinoma, ileus, and
Although four-phase CT is also the initial imaging choice in
stula [2,5,9,19]. The AUA state that ureteric stenting is
children [4,9,23], the European Society of Paediatric Radiology
preferable to percutaneous drainage in the delayed
(ESPR) recommend that ultrasonography (US) with Doppler
management of urine leak, and recommend that it is
can be considered in mild or moderate paediatric trauma
combined with an initial period of catheterisation to assist
if a low threshold for proceeding to CT is maintained [23].
resolution [9]. Figure 1 shows a suggested algorithm for
Although adult criteria for initial imaging are generally
managing grade I to IV renal trauma.
applicable to children, shock is an unreliable sign [4,5,9].
There is conicting guidance about the amount of
The Intraoperative Consult non-visible haematuria required to merit imaging in the
haemodynamically stable child [4,5,23]. While the EAU
The ideal management of renal injury in the context of a
and ESPR recommend that imaging is necessary with any
patient undergoing laparotomy for severe bleeding or
amount of non-visible haematuria [4,23], the renal trauma
intraperitoneal injuries is another dicult and highly
subcommittee advise that it is only necessary if there are >50
controversial scenario. While exploration is mandated in the
red cells/high-power eld [5].
presence of a large, expanding, pulsatile retroperitoneal
haematoma [4,5,8], or a persistently unstable patient despite Unfortunately, renal trauma is uncommonly an isolated injury
exclusion of other abdominal causes, optimum management and usually occurs along with injuries to other organ systems
in other situations is less clear. If preoperative imaging is not [14,24]. This can result in competing imaging and treatment
available then a one-shot IVU is a useful tool in assisting priorities, resulting in the gold standard initial imaging not
decision making [4,5,9,11,21,22]. An abnormal IVU is always being readily available. The EAU recommends that
considered an indication for renal exploration, and a normal patients with multiple injuries should be evaluated on the
IVU (or absence of a contralateral kidney) may discourage basis of the most threatening injury [4]. This supports the
renal exploration due to the risk of unnecessary prioritisation of obtaining gold standard initial imaging in
nephrectomy [4,5,11,22]. If preoperative imaging is available, patients in whom renal trauma is suspected to be the most
algorithms produced by both the EAU and renal trauma signicant injury, which may include patients with severe
subcommittee suggest proceeding to renal exploration at haematuria or penetrating ank trauma, that are stable enough
laparotomy in the presence of a grade III renal injury [4,5]. for CT. Intraoperative IVU is a useful adjunct to ndings at
However, the belief that renal injuries should only be laparotomy for assessing the need for renal exploration in
explored on their own merits, regardless of the patient patients too unstable for preoperative imaging [5,9,21]. If
undergoing laparotomy, is felt to be a commonly used and inadequate initial renal imaging is available, a low threshold
sensible approach [18]. This approach avoids the potential must be maintained for obtaining early re-imaging in the form
consequences of renal exploration, which include of a four-phase CT.

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McCombie et al.

Fig. 1 Algorithm for managing grade I to IV renal trauma.

Grade I Grade II or III Grade IV

Consider Stable
early Stable Unstable
discharge

Low-grade conservative management: Are ALL of the following true? Is intervention required for BLEEDING? Consider:
- Twice daily bloods initially - Stable enough for embolisation - Penetrating injury mechanism
- Twice daily examinations initially - Injury amenable to embolisation Yes - Extravasation of intravascular contrast
- No antibiotics unless febrile/risk factors - Not requiring laparotomy - Medial laceration
- Bed rest until haematuria is light - Embolisation readily available - Peri-renal haematoma diameter > 3.5 cm
- No routine early re-imaging
No

Yes No

Is intervention required for URINE LEAK? Consider:

Embolisation Renal exploration - Large medial urinoma

- Absence of contrast in the distal ureter

Yes No

Ureteric stenting or High-grade conservative


renal exploration management:
- Bloods every six hours initially
- Examinations every six hours
initially
- Prophylactic antibiotics (48-72
hours intravenous, 5 days oral)
- Bed rest until haematuria is light
- Routine early re-imaging at about
48 hours

management in three out of 177 patients, and each of these


Early Re-imaging
had an injury involving the collecting system [26]. Shirazi
While there is a consensus that patients who deteriorate et al. [27] went even further in concluding that even injuries
clinically should either undergo intervention or re-imaging involving the collecting system do not require routine
[35,9], it is less clear whether certain patients who remain re-imaging. In a cohort of 94 patients with a grade III or
stable on conservative management may benet from routine IV injury, they found that all patients who developed
early re-imaging. Blankenship et al. [25] initially proposed that complications had clinical manifestations that would have
routine early re-imaging was necessary in all renal trauma of prompted re-imaging in any case [27]. Finally, Bukur et al.
grade III, based on the high complication rate in this group. [28] reported on a series of 120 patients in whom re-imaging
This recommendation was subsequently rationalised by was only performed in patients with concerning clinical
Malcolm et al. [26], who recommended that routine features. Using this policy repeat imaging was limited to 18
re-imaging in grade III and IV vascular injuries was of 120 patients, with no adverse events reported in those
unnecessary. This was because routine re-imaging was only not re-imaged [28]. Although some of these studies were
found to contribute to a decision to deviate from conservative published after the release of their guidelines, the EAU

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Table 2 Recommendations on initial imaging and early re-imaging. should be tailored to the patients clinical status but should
1. Criteria for initial imaging in adults are: visible haematuria, non-visible
include heart rate, blood pressure, respiratory rate, oxygen
haematuria with shock, penetrating injury, signicant associated injuries, and high- saturation and temperature measurements. Monitoring urine
risk injury mechanisms (B) output and severity of haematuria is also important and is
2. Criteria for initial imaging in children are: any haematuria, penetrating injury,
signicant associated injuries, and high-risk injury mechanisms (B)
most accurately done after insertion of a urinary catheter.
3. Four-phase CT is the imaging method of choice for initial imaging. US with Although some patients may require this to manage their
Doppler can occasionally be considered in very mild paediatric trauma (B) haematuria in any case, placement of a urinary catheter for
4. Clinical deterioration should prompt consideration of re-imaging or intervention.
Examples of deterioration may include: fever, a falling haemoglobin, new or
monitoring purposes is particularly useful in patients with
persistent haemodynamic instability, or worsening pain or abdominal signs (C) haemodynamic instability, high-grade or multiple injuries, or
5. If initial imaging is adequate then routine early re-imaging is not required in signicant co-morbidities. The most important blood tests
grade IIII renal trauma. Routine re-imaging is recommended for all grade IV or
V renal trauma at 48 h (B)
in the initial assessment of patients with renal trauma are
6. US with Doppler is recommended for early re-imaging in children, whereas haemoglobin and creatinine [4]; ensuring the patient has a
four-phase CT is recommended in adults (B) valid cross-match or group and hold is also paramount. After
initial assessment, serial haemoglobins are a useful tool in
assessing for ongoing bleeding [4]; the required frequency of
currently recommends routine early re-imaging after any these is less clear, although some advocate taking samples
signicant renal trauma, whereas the AUA and renal trauma every 6 h for the rst 24 h [26,27]. Initial and subsequent
subcommittee recommend it only for grade IV or V clinical examinations should aim to detect both the presence
lacerations [4,5,9]. If routine early re-imaging is ever and progression of renal injuries and injuries to other organ
indicated, the guidance for the ideal timing of it is unclear systems. Signs suggestive of possible renal injury include:
[4,5,9,23]. The ESPR (424 h), renal trauma subcommittee haematuria, penetrating wound in the vicinity of a kidney,
(3648 h), AUA (>48 h), and EAU (24 days) all recommend ank bruising, fractured ribs, an abdominal mass, and
obtaining routine early re-imaging after slightly dierent abdominal tenderness or distension [4,5,9]. Assessing for
intervals [4,5,9,23]. developing peritonitis is particularly important given this is a
CT is regarded as the method of choice for early re-imaging in common cause for failure of conservative management and
adults [4,5,9]; however, US with Doppler is recommended in hollow visceral injuries are not always readily apparent on
children [23]. In 71 children sustaining renal trauma, US initial imaging [34]. The required frequency of clinical
proved sucient in detecting four enlarging perinephric examinations is not clear, although some advocate repeating
collections and a pseudoaneurysm, and CT was only required this up to every 4 h initially [27]. Reducing the intensity of
in two patients to better dene a urological complication [29]. monitoring after 24 h seems reasonable, as 87% of patients
Given the good experience with US in children [29], the low who fail a trial of conservative management do so within this
yield of routine early re-imaging [26,27], and the radiation time frame [34].
risks of CT [30], it may be that US has a useful role in the
early re-imaging of adult trauma that has yet to be dened Thromboprophylaxis
(Table 2). Trauma patients are known to be at high-risk of venous
thromboembolism (VTE), and this risk can be reduced
Initial Monitoring
signicantly with mechanical and pharmacological
While it is common practice to admit all patients sustaining thromboprophylaxis [35]. Small dierences between the
renal trauma for a period of observation, discharge from the ecacy of dierent methods of thromboprophylaxis make
emergency department may be considered for patients with drawing absolute conclusions dicult; however, it appears as
grade I injuries without visible haematuria [31]. Routine though low-molecular-weight heparin may be superior to
admission of patients with high-grade injuries to the intensive either unfractionated heparin or mechanical prophylaxis in
care unit (ICU) is rarely described for adults; however, appears reducing the risk of VTE after trauma [35]. However, while
more common for children [6,31]. This practice has been mechanical prophylaxis in the form of anti-embolism
questioned in view of the reductions in ICU admissions that stockings and intermittent pneumatic compression devices
have been safely achieved in paediatric hepatosplenic trauma appears relatively safe and eective, many clinicians do not
[32,33], when these patients are considered to have a higher feel comfortable with prescribing unfractionated or
risk of uncontrollable haemorrhage than those with renal low-molecular-weight heparin in the context of known renal
trauma [6]. Monitoring of paediatric patients sustaining renal injury due to the considered increased bleeding risk [35].
trauma on surgical wards is thought to be an under-reported
Providing specic guidance on thromboprophylaxis in renal
phenomenon [6].
trauma is dicult because there is a lack of evidence specic
Monitoring should include regular observations, blood tests to renal trauma on which to base recommendations currently.
and clinical examinations. The frequency of observations Additionally, decisions about thromboprophylaxis have to

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McCombie et al.

consider multiple dierent factors including: haematuria, Table 3 Recommendations on inpatient management.
other injuries, medications, and risk factors for VTE. 1. Admission of all patients for at least 24 h observation, except those with grade I
Trauma-specic risk-factors for VTE that should be injuries without visible haematuria (C)
considered include: age, need for major surgery, specic 2. Admission of patients to ICU should be based on factors such as haemodynamic
instability and other injuries, as opposed to routinely admitting patients based on
injuries (pelvic or lower extremity fracture, head or spinal trauma grade (C)
cord injury, venous injury), and markers of being critically 3. Regular observations, blood tests and clinical examinations are required. The
unwell (shock on admission, >3 ventilator days) [35]. frequency of these must be tailored to both the patient and injury; however, serial
examinations and haemoglobin concentrations up to every 6 h may be
appropriate in grade IV or V trauma for the rst 24 h (C)
Bed Rest and Discharge Criteria 4. Thromboprophylaxis must be decided on a case-by-case basis. Unless
contraindications exist, anti-embolism stockings are recommended throughout
Prescribing bed rest after renal trauma dates back to an era admission and intermittent pneumatic compression devices are recommended
before CT; the original paper advocating it is from 1968 and while the patient is immobile. Routine use of low-molecular-weight or
unfractionated heparin is not recommended currently (C)
recommends 3 weeks of bed rest, with the rst of these 5. Bed rest should continue until haematuria is light without the need for bladder
occurring in hospital [36]. Yet despite the advent of CT, irrigation or manual bladder washouts (C)
meaning that we now know much more about the injuries 6. General discharge criteria such as being afebrile, tolerating a normal diet,
adequate pain management, and stable blood tests apply (C)
we manage, assigning bed rest is still very common practice
[4,5,11,14,31]. Most of those who advocate bed rest
recommend continuing it until the resolution of visible
Table 4 Recommendations on antibiotics.
haematuria [3,4,11,31]; however, this policy has been
challenged for two reasons [6,24]. Firstly, the degree of 1. In the absence of fever and risk factors (e.g. devitalised segments, signicant soft
haematuria does not appear to correlate with either symptom tissue loss, bowel or pancreatic injury, immunosuppression):
Injuries of grade IIII do not require antibiotics (C)
improvement or mobility [24]. Secondly, it leads to
Injuries of grade IV and V should receive i.v. antibiotics for 4872 h, followed
prolonged admissions [6] with the associated risks of VTE by a 5-day course of oral antibiotics (C)
and hospital-acquired infections of this. Reports of average 2. In the presence of fever or risk factors, injuries of any grade should receive i.v.
lengths of stay of >1 week in low-grade trauma [37,38] are antibiotics for at least 4872 h, followed by a 5-day course of oral antibiotics (C)
3. Unless contraindicated, our preference is for the i.v. or oral antibiotic to be
probably a consequence of this policy, and do seem a rst-generation cephalosporin. These agents generally have good
excessive. This is particularly so when other studies report anti-staphylococcal cover, reasonable gram-negative cover, an excellent safety
safely achieving an average length of stay of <4 days in prole, and a low risk of selecting multi-resistant organisms if used for a short
duration. Alternative options include ciprooxacin or combined treatment with
isolated renal injuries across all trauma grades, using a more ampicillin and gentamycin (C)
liberal policy on mobilisation [24]. Equally, reports of an 4. Any concomitant bowel injury requires additional anaerobic cover in the form of
average length of stay of <2 days in hepatosplenic trauma, metronidazole. An alternative option is clindamycin (C)

with no re-admissions [33], suggests periods of prescribed


bed rest may be able to be safely reduced in renal trauma.
Results of a prospective study examining the eect of and perinephric abscess, which have reported incidences of
allowing early mobilisation and discharge, regardless of 511% [25,38] and 05% [2] respectively, and an associated
ongoing visible haematuria, are eagerly awaited [6]. Apart increased mortality risk. Devitalised segments, signicant
from haematuria, other general discharge criteria apply in soft tissue loss, and concomitant bowel or pancreatic injury
renal trauma; being afebrile, tolerating a regular diet, appear to increase these risks [39]. Patient factors including
adequate pain control, and maintaining a stable haemoglobin age, co-morbidities and immunosuppression must also be
are not contentious criteria (Table 3). considered (Table 4).

Antibiotics Return to Activity


Prophylactic antibiotics are often advocated after renal Neither the EAU, AUA, or renal trauma subcommittee provide
trauma [4,6,10,27]; however, it is agreed that there is recommendations about timing of return to normal activities
minimal evidence to support this practice [2,6]. The most or sport after conservatively treated renal trauma [4,5,9].
suitable agents and duration of treatment have yet to be Concerns related to return to activity are mainly related to a
dened, and few specic recommendations exist. Equally, it considered increased risk of secondary haemorrhage while the
is not clear whether all patients require antibiotics; some injured kidney is still healing, although this has never been
have suggested limiting their use to injuries involving the proven. Secondary haemorrhage occurs in up to 25% of
collecting system [2,8,11,14], or those with an associated conservatively managed injuries of grade III [2,5], and
large haematoma [2]. In one study of grade IV injuries, it is usually caused by a ruptured pseudoaneurysm or an
patients were not given prophylactic antibiotics and 5% arteriovenous stula [5,11,40]. It usually occurs within the rst
ultimately required nephrectomy for sepsis [19]. The 6 weeks, with patients seemingly most susceptible in the rst 2
rationale behind their use is to reduce the incidence of UTI weeks [2,5,10,40]; it does not therefore seem unreasonable to

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Table 5 Recommendations on return to activity. stulae are the commonest causes of secondary haemorrhage
1. Long-haul travel and return to remote areas is not recommended for 2 weeks
[2,5,40], and occur almost exclusively in injuries of grade III
after renal trauma (C) [2,40]. Patients usually present with haematuria [2,40], often
2. Patients should be allowed to return to normal everyday activities, such as school within 2 weeks of the injury [2,10,40]; however, reports of
and work, as tolerated after discharge (C)
3. Patients should be advised against sports for at least 6 weeks after grade I injuries,
detection up to 20 years after renal trauma suggests they can
and at least 3 months after injuries of grade II. Radiological resolution should progress asymptomatically [2,10,40,49]. Although commonly
also be conrmed before permitting return to sports, in all but grade I injuries (C) diagnosed on CT, Doppler US has successfully detected both
4. Patients should be counselled about the risks of dierent sporting activities after
renal trauma, particularly if they have a residual poorly- or non-functioning
[2,29,40]. Hydronephrosis can progress asymptomatically after
kidney. However, advising against ongoing participation in sports for patients renal trauma, and have a deleterious eect on kidney function
with residual poorly- or non-functioning kidneys does not appear warranted (C) [2]; US is equivalent to CT for its detection.
For healing of known injuries, healing time has been shown to
be proportional to the size of associated haematoma [50].
recommend patients avoid long-haul travel and return to While 6080% of injuries have completely healed by 1 month,
remote areas during this 2-week period. up to 3 months may be required for higher grade injuries
Prescribed periods of activity restriction are very common after [42,51]. Ensuring adequate healing of a renal injury may
any solid abdominal organ trauma; about three-quarters of enable clinicians to better counsel patients on issues such as
paediatric surgeons recommend 23 weeks o of school and return to sporting activities, although radiological healing may
23 months o of sports after an injury [41]. Some advocate not equate to physiological healing.
using radiological resolution of the injury as a guide to allowing Follow-up imaging in the absence of concerning clinical
return to sporting activities [4143]. While guidance after renal manifestations has been shown to result in the need for
trauma is limited, the American Paediatric Surgical Association intervention in <1% of patients [51]. It is for this reason that
has made clear recommendations for hepatosplenic trauma some authors have recommended restricting its use to
[44]; the suggested period of activity restriction in weeks equals collecting system injuries [6] or grade V injuries [51]; others
the grade of the injury plus two [44]. Furthermore, studies have have proposed abandoning follow-up imaging altogether [28].
reported no re-admissions when allowing patients with Although US with Doppler is recommended for follow-up
hepatosplenic trauma to return to non-contact activities on imaging in children [23], the ideal method in adults is less
discharge, and contact sports at 46 weeks [33,43]. clear. The low incidence of signicant abnormalities
The incidence of sport-related traumatic kidney injury is developing asymptomatically after the rst 48 h [51],
6.9/million people [45]. However, the incidence of combined with the radiation risks of CT [30], make it dicult
catastrophic injury, resulting in nephrectomy, is very low at to justify using CT for follow-up imaging routinely.
0.4/million people [45]. Studies agree that the likelihood of In addition, radionuclide scintigraphy is useful for monitoring
sustaining a traumatic brain injury is signicantly higher; functional recovery of a traumatised kidney, and DMSA scans
relative risks of ve and 67 have been reported [46,47]. seem to be the preferred option [4,5,11,52,53]. Results of
Additionally, the risk of sustaining a traumatic kidney injury radionuclide scans correlate well with the grade of injury, with
during a road trac accident is up to three-times higher than low-grade injuries rarely resulting in signicant dysfunction
the risk of sustaining one during sport [47]. While most [52,53]. In addition to grade IV and V injuries [5,52,53], new
consider contact sports to be most risky, the evidence suggests hypertension appears to be a useful indication for obtaining
cycling, equestrian, and snow sports are more commonly this investigation [29]. The timing of radionuclide scans
responsible [47,48]. There have been no documented cases of appears unimportant: serial split functions remain almost
kidney loss due to sport-related trauma in patients with a identical at 8 days and 6 months [53], or 3 months and 1 year
solitary functioning kidney [47,48]. Although most clinicians [52]. Results do not necessarily aect management; however,
may advise patients with a solitary functioning kidney against may be useful when counselling patients and in guiding need
participation in certain sports [48], numerous studies conclude for nephrological follow-up [52].
that restricting exposure to sports is not justied in this group
[4648] (Table 5). Clinical Follow-up
Clinical follow-up after renal trauma allows symptoms,
Follow-up Imaging examination ndings, blood pressure, serological renal
function, and resolution of non-visible haematuria to be
The purposes of follow-up imaging are to exclude
monitored [4]; it also prompts the clinician to review any
development of new pathologies, and to show adequate
follow-up imaging that has been obtained.
healing of known injuries. Pathologies of particular
importance include pseudo-aneurysms, arteriovenous stulae, The pathophysiology of post-traumatic hypertension is
and hydronephrosis. Pseudo-aneurysms and arteriovenous thought to relate to the increased production of renin in

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BJU International 2014 BJU International 19
McCombie et al.

Table 6 Recommendations on follow-up. should involve. The available literature has been reviewed and
1. Except patients with grade I injuries, all patients should be oered outpatient
consensus recommendations made by a multi-disciplinary team
follow-up at 46 weeks; earlier appointments may be appropriate in some consisting of experienced urologists, radiologists, and infectious
instances (C) disease physicians. These recommendations have undergone
2. Except patients with grade I injuries, US with Doppler is recommended for all
patients before outpatient follow-up at 46 weeks. If adequate healing is not
formal review and debate at the Western Australian USANZ
demonstrated, further US every 46 weeks should be considered until adequate 2013 state conference, and have been presented at the USANZ
healing is achieved (C) 2014 annual scientic meeting. They therefore reect both
3. If examination ndings, radiology, blood pressure, and serum renal function are
all normal at rst outpatient appointment, further urological follow-up is not
best-available evidence, and a consensus of expert opinion. It is
mandated but the patient should be followed up by their GP (C) hoped that these recommendations may help standardise the
4. A DMSA scan at 612 weeks should be considered for all patients sustaining conservative management of renal trauma, and provide
grade IV or V renal trauma (B), or those who develop hypertension (C)
5. GP follow-up after renal trauma should involve:
stimulus for debate and further research.
Twice yearly blood pressure checks for 2 years, followed by lifelong annual
blood pressure checks (C)
Conrmation of resolution of non-visible haematuria at 6 months (C) Conflict of Interest
6. Non-visible haematuria that persists beyond 6 months should be investigated in
the usual way (C) None declared.

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