Management of traumatic injury to kidney allograft: A narrative review

Abstract

Trauma to a transplanted organ is rare, but clinicians increasingly confront this scenario with the rise in transplantations. Renal trauma requires multidisciplinary treatment, and guidelines are necessary for standardizing medical care. However, there are no diagnostic and treatment protocols for traumatic renal injury in transplanted kidneys. This review aims to consolidate current knowledge on the interdisciplinary approach to managing injuries of transplanted kidneys, with a focus on blunt trauma to the abdomen and pelvis. Transplanted kidneys, typically placed in the iliac fossa in a heterotopic, extraperitoneal position are more exposed to direct trauma, particularly in motor vehicle accidents. In the emergency setting, the initial imaging is often an Ultrasound scan. This bedside ultrasound helps identify free fluid in the abdomen, indicating possible bleeding and guiding the need for surgical intervention. However, Ultrasound scan is operator-dependent and has limited sensitivity for low-grade renal trauma. Hemodynamically stable patients, or those who stabilize with resuscitative efforts, should undergo contrast-enhanced CT or MRI for a more accurate assessment. Therapeutic strategies may include conservative management, radiological interventions such as angioembolization, or surgical exploration, depending on hemodynamic stability, the severity of injury, and the degree of graft dysfunction. Surgical intervention is reserved for patients who are hemodynamically unstable despite resuscitative efforts or who fail conservative treatment. Management of renal trauma in this population of patients requires a multidisciplinary approach involving transplant surgeons, nephrologists, interventional radiologists, and trauma specialists. Prospective and multicenter studies are lacking, and further research is warranted to compare outcomes of operative, non-operative, and interventional radiologic approaches in high-grade injuries (grades IV and V), and establish criteria for follow-up imaging in renal trauma.