The characteristics,management and outcomes of high- and low-grade renal injuries in paediatric trauma patients at a major trauma centre

Abstract

Introduction

Children, given anatomical variations, are at increased risk of renal injury following trauma. The management of paediatric renal injuries has, similar to other solid organ injuries, largely shifted towards conservative management; however, hemodynamically unstable patients may still warrant surgical exploration or interventional techniques. The aim of this study is to describe the local incidence, demographics, morbidity and outcomes associated with high- and low-grade renal injury in a paediatric major trauma population.

Method

This was a 5-year retrospective review of trauma registry data and chart analysis of all paediatric renal injuries from major trauma at a North American level 1 paediatric trauma centre between January 2016–31 December 2020. Data was analysed using SPSS v27 with p < 0.05 considered significant.

Results

Of 1334 major trauma patients, 45 suffered a kidney injury (20 high-grade and 25 low-grade injuries), of which 93.3% underwent conservative management with no difference in outcomes between groups. 80% of patients had concurrent injuries (a quarter requiring surgery for these), with a trend towards higher rates of chest injuries in high-grade renal injury patients (p = 0.08). Bicycle injuries were statistically more likely to cause high-grade renal injury (p = 0.02). Angiography was utilized infrequently (3/45 patients, 6.6%), and no patients underwent embolization in our study population. Overall mortality (4.4%) and length of stay were unaffected by grade of injury.

Conclusion

Paediatric renal injury is an uncommon injury in major trauma patients (3.4%). Most cases can be managed conservatively regardless of the grade of injury. Renal injury patients are likely to have concurrent injuries, often requiring surgery. Further studies are needed to measure the success and utilization of interventional radiology techniques for management in children.

Keywords

Paediatric kidney major trauma injury

Introduction

Injury remains the leading cause of death and disability in Canadian children and youth, and abdominal trauma is an important contributor to morbidity, and sometimes mortality.

Children are more vulnerable to sustaining significant abdominal trauma given their unique anatomic characteristics. Relatively compact torsos with smaller anterior-posterior diameters reduce the area over which the force of the injury can be dissipated. Larger viscera, including their liver, spleen and kidneys, extend below the costal margin and the bladder sits intra-abdominally instead of protected within the pelvis, making these organs vulnerable.¹ Additionally, children often have less overlying fat to cushion intra-abdominal structures from blunt force. Physiologic differences in children that allow for robust vasoconstriction and natural haemorrhage control² also allow for the majority of abdominal trauma in children (as now also in adults) to be safely managed conservatively and rarely requiring operative intervention.^2–10 Furthermore, the World Society of Emergency Surgery and the American Association for the Surgery of Trauma (AAST) guidelines state that non-operative management (NOM) should be the treatment of choice for all hemodynamically stable or stabilized minor-moderate (AAST I-II and III) and severe (AAST IV-V) lesions.^11,36 In their study outcomes, no specific recommendations exist for NOM in blunt and penetrating kidney injuries in children that are different than those used for adults.¹²

The literature currently lacks definitive data on the management and outcomes specifically of paediatric renal trauma patients, and controversy still exists about the role of conservative management in high-grade injuries in this cohort.^13–15 In adults’ angiography and embolization use is increasing for kidney injuries, yet there is little in the literature for the paediatric population. Current indications for angiography and embolization in children are not universally recognized, but include moderate and severe injuries, active bleeding with contrast blush on CT-scan and ongoing haemodynamic instability.¹²

The purpose of this study was to determine the incidence, demographics, morbidity and outcomes associated with high- and low-grade kidney injuries resulting from major trauma in a paediatric population within a single level 1 paediatric trauma centre in North America.¹⁶

Method

A retrospective chart and trauma registry review of paediatric (< 17 years old) trauma admissions from 1 January 2016 to 31 December 2020 was performed. Approval for the study was granted by the Hospital for Sick Children, Research Ethics Board Review Board. The Hospital for Sick Children is a major trauma centre providing care to children across Ontario, Canada.

Trauma patients were identified as those meeting requirements for level 1 or level 2 trauma team activation in the emergency department (ED) or patients whom did not receive a level 1/2 call but had injury severity scores (ISS) ≥ 12 (i.e. trauma transfers with significant injuries or walk-ins found to have severe injuries on imaging).

The patient demographics, injury type, associated injuries, ISS, length of stay (LOS), management (surgical, embolization, conservative and use of haemostatic resuscitation) and the kidney injury grading were reviewed. The AAST renal injury grade was determined by chart review using EPIC/Kidcare, as well as review of computed tomography (CT) reports and operation notes. Renal injury grades were divided into low- (I–III) and high-grade (IV–V) injuries for comparison using the AAST classification.

Categorical variables were compared using Pearson chi-squared and Fisher’s exact test, with p ≤ 0.05 considered as a significant result. Statistical analysis was conducted using SPSS V27.

The primary outcome was mortality; secondary outcomes included operative management, blood products, hospital LOS, intensive care unit (ICU) LOS and concurrent injuries sustained between the two groups.

Results

Overall, 1334 major trauma patients attended the Hospital for Sick Children during the study period, with a mortality rate of 3.1% (41 patients) -45 patients sustained a direct injury to their kidneys (3.4%); of these, 20 patients had high-grade and 25 had low-grade renal injuries. The median age was 17 and 15 years, respectively, with a range of 1–17. No difference was seen in primary trauma numbers versus secondary transfer between groups, and injury severity scores were similar. When comparing the mechanism of injury, bicycle injuries were statistically more likely to cause high-grade renal injury (p = 0.02) (Table 1).

Table 1.

Demographics for renal trauma according to grade of kidney injury. MTC, major trauma centre; ISS, Injury Severity Score; MVC, motor vehicle collision.

Demographics	Total direct kidney injuries	High-grade kidney injuries (IV and V)	Low-grade kidney injuries (I-III)	p value
Total	45	20 (44.4%)	25 (55.6%)	0.58
Male	29 (64.4%)	12 (41.4%)	17 (58.6)
Female	16 (35.6%)	8 (50%)	8 (50%)
Age range (years)	1–17	1–17	3–15	0.57
Median age	11	10	12
Blunt	44 (97.8%)	20 (45.5%)	24 (54.5%)
Penetrating	1 (2.2%)	0 (0%)	1 (100%)
Primary trauma	20 (44.4%)	10 (50%)	10 (50%)	0.5
Secondary trauma transfer to MTC	25 (55.6%)	10 (40%)	15 (60%)
ISS scores				0.07
ISS score range	5–57	16–50	5–57
Median	17 (IQR, 15.5–27.5)	25	16
Mechanism
Fall	11 (24.4%)	5 (45.5%)	6 (54.5%)	0.7
Penetrating	1 (2.2%)	0 (0%)	1 (100%)	0.2
MVC	17 (37.8%)	5 (29.4%)	12 (70.6%)	0.1
Sport	7 (15.6%)	3 (42.9%)	4 (57.1%)	0.9
Bicycle	9 (20%)	7 (77.8%)	2 (22.2%)	0.02

Only 9/45 (20%) patients suffered an isolated kidney injury, of which seven were high-grade injuries (p = 0.02). There was no significant difference between groups for bilateral renal injury, associated liver or splenic injury or neuro trauma (Table 2).

Table 2.

Associated injuries according to grade of kidney injury.

Injuries sustained	Total direct kidney injuries	High-grade kidney injuries (IV and V)	Low-grade kidney injuries (I-III)	p value
Isolated kidney injury	9 (20%)	7 (77.8%)	2 (22.2%)	0.02
Associated liver injury	19 (42.2%)	8 (42.1%)	11 (57.9%)	0.7
Associated spleen injury	14 (31.1%)	5 (35.7%)	9 (64.3%)	0.4
Associated chest injury	7 (15.6%)	1 (14.3%)	6 (85.7%)	0.08
Associated brain injury	7 (15.6%)	2 (28.6%)	5 (71.4%)	0.3
Bilateral kidney injury	3 (6.7%)	1 (33.3%)	2 (66.7%)	0.6

Overall, 22% of patients with a direct kidney injury required operative management for their traumatic injuries, though only 6.7% of patients required operative management specifically for their renal injury; three patients underwent laparotomy, two for low-grade and one for high-grade injuries with one nephrectomy for high-grade injury. Three patients required angiography (6.7%) (two low-grade and one high-grade); no patients received embolization.

Just over a quarter (29%) of patients required ICU admission, with no difference between groups or ICU LOS which ranged from 0 to 48 days (Table 3). Overall mortality for patients with renal injury was 4.4% (3.1% of all 1334 major trauma patients during the study period). There was no significant difference between groups for blood requirements (p = 0.4) or for mortality (p = 0.1) (Table 3).

Table 3.

Outcomes for high-grade versus low-grade kidney injury. IQR, interquartile range; SD, standard deviation; PICU, paediatric intensive care unit.

Operating room (OR) requirements	Total direct kidney injuries	High-grade kidney injury (IV and V)	Low-grade kidney injury (-III)	p-value
Patients requiring the OR	10	6	4	0.2
Range of number of OR surgeries required per patient	0–11	0–11	0–4
Mean number of surgeries per patient	—	1	0.028
Operative management of kidney injury
Laparotomy	3	1	2	0.6
Angiograph	3	1	2	0.6
Nephrectomy	1	1	0	0.2
Length of stay (LOS)	0–64 days	0–49 days	0–64 days	0.4
Median LOS	5 (IQR, 3–13)	5	5
IQR	10	11	8.5
SD	14.5	11.7	12.9
PICU admission	13 (28.9%)	7 (53.8%)	6 (46.2%)	0.4
PICU LOS (days)	0–48	0–13	0–48	0.1
Median PICU LOS	0 (IQR, 0–1)	0	0
Mean PICU LOS	—	1.8	2.6
Ventilation
Mechanical ventilation requirements	9	4	5	0.6
Blood
Blood within 1st 24 h	10 (22.2%)	6 (60%)	4 (40%)
Blood requirement throughout LOS	11 (24.4%)	6 (54.5%)	5 (45.5)
Mortality	2 (4.4%)	0	2 (100%)	0.1

Discussion

At a high-volume tertiary paediatric trauma centre in Canada, the incidence of kidney injury was rare (3.4%). Of those that did have a kidney injury, the split between high-grade and low-grade was 44.4% and 55.6%, respectively, with conservative management being achieved in 93.3%. Despite conservative management for the direct renal injuries in our study population, most children with renal injury had concurrent injuries (80%), with just under a quarter requiring operative management for these other injuries and a quarter requiring blood/blood products. Of the 6.7% of patients requiring surgery for a direct kidney injury (laparotomy), two patients went straight to the operating room (OR) from the ED, and one to the paediatric ICU prior to OR. The mechanisms of injury for these patients were MVCs in two and one penetrating gunshot wound injury.

In our study, the majority of renal injuries were managed conservatively, even when high-grade, which is similar to the current literature that demonstrates nephrectomy rates in these patients (2.2%) are rare.^16–19 These rates are lower than those in the adult population where the incidence is approximately 6%,^20–22 despite the anatomical vulnerability of these organs in children.^20–22 The grade of renal injury should therefore not be the only parameter used to decide on surgical management or nephrectomy for traumatic injury to the kidney, particularly in children. Haemodynamic status, concurrent injuries and requirement for haemostatic resuscitation acutely should be taken into account in decisions regarding operative management. Angiography was rarely utilized (3/45 patients, 6.6%), and no patients underwent embolization in our study. Similarly, Graziano et al. showed embolization rates of 1.4% and Ishida et al., 1.5%. We may be limited in our study to capture these rare events given the infrequent occurrence of this important intervention.^16,22 Furthermore, the only nephrectomy in our patient cohort occurred in the acute period where the patient went from the trauma bay to the OR immediately.

This nephrectomy was for an avulsion to the upper pole of the left kidney (Grade 5 injury) with urinary extravasation. The remaining two surgical laparotomy patients underwent renal repairs, further details of which were not highlighted in the initial data. These interventions were all ‘early’, and it is important to note that no ‘late’ interventions (ureteric stent or nephrostomy) were required for ongoing urinary leak or late nephrectomy.

Hospital and ICU LOS did not differ between groups. This is consistent with previous studies that demonstrate hospital LOS did not increase with worsening severity of renal injury, and instead was determined by the severity of the non-renal-associated injuries.^16,23,24 This suggests that renal trauma in isolation has a consistent prognosis between groups and other associated injuries are the factors that prolong LOS. However, associated injuries in these patients are significant with a high overall mortality rate of patients with renal injury (4.4%) compared to all mortality rates for our institution (3.1%) for major trauma. Across the world, in-hospital mortality of paediatric trauma patients is reported to vary from 0.3% to 8.5%.^25–32 Mortality in all cases from this cohort was related to concurrent severe brain injury.

Although there is no difference in ICU stay or hospital LOS between our two groups, it is important to note that there is also no significant difference in important associated injuries. For example, multiorgan injury, specifically neuro trauma, is related to a higher degree of mortality. Our results demonstrate that these important contributors of morbidity were similar between the two groups. Injuries such as intra-abdominal (liver and spleen), head injury and chest trauma that typically cause ICU admission were present in both cohorts.

Although most renal patients did not require surgery for their injuries, it is possible that acute kidney injury (AKI) from their injuries contributed to their ICU requirement/organ support needs. However, the overall LOS was likely related closely to other concurrent injuries. We do not have information on creatinine/urine output in order to characterize AKI in this patient cohort.

The trend towards chest injury and high-grade kidney injury can be explained by the fact that the kidney’s position is relatively high in the abdominal cavity. The thorax needs to be evaluated thoroughly, particularly for patients with bicycle injuries, who tended to have a higher incidence of high-grade renal injury. The positioning of the handlebars may account for this with direct impact taking most of the force on the upper abdomen/lower chest.^17,19,23,34 Isolated injuries were more likely to be high-grade injuries, perhaps due to more force being applied through a smaller area.

A strength of this study was the comprehensive and meticulous recording of registry data by a single trauma registry analyst, which reduced bias secondary to inaccurate or incomplete data. Limitations included the small number of patients in the cohort, retrospective design for assessing data and insufficient details for certain data elements such as biochemical derangement, urinary output or the presence of acute kidney injury in relation to direct injury. Future research would benefit from multi-centre involvement to more accurately assess the utilization of embolization for this injury type and to further delineate important rare events.

Conclusion

Renal injury in children is uncommon, and management is primarily conservative with low operative rates and distinctly uncommon use of interventional modalities. Mortality rates are high, secondary to concomitant injuries, and high- versus low-grade renal injury did not impact mortality. More data is needed to determine the utility of interventional radiology in paediatric renal trauma.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

This study was obtained from Research Ethics Board at the Hospital for Sick Children Toronto (RE approval number 100,074,627)

Informed consent

Informed consent was not sought for the present study because 5-year data already collected as part of the trauma database and de-identified.

ORCID iD

Ruth Bird

References

Paediatric trauma manual. https://www.c4ts.qmul.ac.uk/downloads/pan-london-paediatric-trauma-manual--compressed.pdf (accessed 28 June 2021).

Hagedorn

Fox

Ellison

, et al. Pediatric blunt renal trauma practice management guidelines: collaboration between the eastern association for the surgery of trauma and the pediatric trauma society. J Trauma Acute Care Surg 2019; 86(5): 916–925.

Fernández-Ibieta

. Renal trauma in paediatrics: a current review. Urology 2018; 113: 171–178.

Abdominal injuries in children (paediatric major trauma manual)

[Internet]. C4ts.qmul.ac.uk. 2021 [cited 14 October 2021]. https://www.c4ts.qmul.ac.uk/downloads/pan-london-paediatric-trauma-manual--compressed.pdf

Brown

Elder

Spirnak

. Are pediatric patients more susceptible to major renal injury from blunt trauma? a comparative study. J Urol 1998: 138–140.

Kuzmarov

Morehouse

Gibson

. Blunt renal trauma in the pediatric population: a retrospective study. J Urol 1981; 126(5): 648–649.

Nguyen

Das

. Pediatric renal trauma. Urology 2002; 59(5): 762–766.

Bent

Iyngkaran

Power

, et al. Urological injuries following trauma. Clin Radiol 2008; 63(12): 1361–1371.

Matlock

Tyroch

Kronfol

, et al. Blunt traumatic bladder rupture: a 10-year perspective. The Am Surgeon 2013; 79(6): 589–593.

10.

Tyroch

Matlock

. Pediatric and adult blunt traumatic bladder rupture: a comparative review. Panamerican J Trauma Crit Care Emerg Surg 2015; 4(1): 11–15.

11.

American association of the surgery of Trauma. https://www.aast.org/Default.aspx (accessed 9 August 2021).

12.

Coccolini

Moore

Kluger

, et al. Kidney and uro-trauma: WSES-AAST guidelines. World Journal Emergency Surgery: WJES 2019; 14(1): 54

13.

Fraser

Aguayo

Ostlie

, et al. Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int 2009; 25(2): 125–132.

14.

Aguayo

Fraser

Sharp

, et al. Nonoperative management of blunt renal injury: a need for further study. J Pediatr Surg 2010; 45(6): 1311–1314.

15.

Rogers

Knight

MacUra

, et al. High-grade renal injuries in children-is conservative management possible?. Urology 2004; 64(3): 574–579.

16.

Ishida

Tyroch

Emami

, et al. Characteristics and management of blunt renal injury in children. J Emergencies, Trauma Shock 2017; 10(3): 140.

17.

Henderson

Sedberry-Ross

Pickard

, et al. Management of high grade renal trauma: 20-year experience at a pediatric level i trauma center. J Urol 2007; 178(1): 246–250.

18.

Buckley

McANINCH

. Pediatric renal injuries: management guidelines from a 25-year experience. J Urol 2004; 172(2): 687–690.

19.

Graziano

Juang

Notrica

, et al. Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children. J Pediatr Surg 2014; 49(1): 198–201.

20.

Aragona

Pepe

Patanè

, et al. Management of severe blunt renal trauma in adult patients: a 10-year retrospective review from an emergency hospital. BJU Int 2012; 110(5): 744–748.

21.

Baverstock

Simons

McLoughlin

. Severe blunt renal trauma: a 7-year retrospective review from a provincial trauma centre. Can Journal Urology 2001; 8: 1372–1376.

22.

Davis

Reed

2nd Santaniello

, et al. Predictors of the need for nephrectomy after renal trauma. J Trauma Inj Infect Crit Care 2006; 60: 164–170.

23.

Broghammer

Langenburg

Smith

, et al. Pediatric blunt renal trauma: Its conservative management and patterns of associated injuries. Urology 2006; 67: 823–827.

24.

Nance

Lutz

Carr

, et al. Blunt renal injuries in children can be managed nonoperatively: Outcome in a consecutive series of patients. J Trauma Inj Infect Crit Care 2004; 57: 474–478.

25.

Aoki

Abe

Saitoh

, et al. Epidemiology, patterns of treatment, and mortality of pediatric trauma patients in Japan. Scientific ReportsPMCID 2019; 9(1): 917. DOI: 10.1038/s41598-018-37579-3.

26.

Govind

Merritt

. A 15 year cohort review of in-hospital pediatric trauma center mortality: a catalyst for injury prevention programming. Am J Surg 2018; 216: 567–572.

27.

Borgman

Matos

Blackbourne

, et al. Ten years of military pediatric care in Afghanistan and Iraq. J Trauma Acute Care Surg 2012; 73: S509–S513.

28.

Snyder

Muensterer

Sacco

, et al. Paediatric trauma on the Last Frontier: an 11-year review of injury mechanisms, high-risk injury patterns and outcomes in Alaskan children. Int J Circumpolar Health 2014; 73: 25066.

29.

St-Louis

Bracco

Hanley

, et al. Development and validation of a new pediatric resuscitation and trauma outcome (PRESTO) model using the U.S. National Trauma Data Bank. J Pediatric Surgery 2017; S0022-3468: 30661–30669.

30.

Burd

Jang

Nair

. Evaluation of the relationship between mechanism of injury and outcome in pediatric trauma. J Trauma Inj Infect Crit Care 2007; 62: 1004–1014.

31.

Janssens

Holtslag

van Beeck

, et al. The effects of regionalization of pediatric trauma care in the Netherlands. J Trauma Acute Care Surg 2012; 73: 1284–1287.

32.

Margenthaler

Weber

Keller

. Blunt renal trauma in children: experience with conservative management at a pediatric trauma center. J Trauma Inj Infect Crit Care 2002; 52: 928–932.

33.

Navascués

Matute

Soleto

, et al. Paediatric trauma in Spain: a report from the HUGM Trauma Registry. Eur J Pediatr Surg 2005; 15: 30–37.

34.

Statistics Canada . Table 13-10-0394-01 Leading causes of death, total population, by age group, https://doi.org/10.25318/1310039401-eng (accessed 28 July 2021).

35.

World society of emergency surgery. https://www.wses.org.uk (accessed 9 August 2021).