INJURIES TO THE KIDNEY: Prof.Abdulrazzaq Al-Salman
Either
1-Open (penetrating ) injury,which need immediate surgical intervention.or
2-Closed (blunt truma) injury.
In civilian life, injuries to the kidney result most often from either
blows or falls on the loin or crushing injury to the abdomen, typically in a
road traffic accident. Haematuria after trivial injury to the kidney should
suggest the possibility of a pre-existing disease, e.g. calculus,hydronephrosis
or tuberculosis.The degree of injury varies considerably from a small
subcapsular haematoma to a complete tear through the kidney .
Types of closed renal trauma: (minor(1,2,3) and major(4,5)this
classification depend on findings in investigations like CT with contrast
Grade 1:renal contusion and /or nonexpanding subcapsular haematoma.
Grade 2:laceration less than 1 cm in depth sparing the renal medulla and
collecting system and/or nonexpandig retroperitoneal hematoma.
Grade 3:laceration more than 1 cm sparing the collecting system.
Grade 4:laceration more than 1 cm involving the collecting system and/or
renal vessels injury with hemorrhage.
Grade 5:shattered kidney and/or avulsed renal vessels.
The kidney may be partially or wholly avulsed from its vascular pedicle;
one pole may be completely detached. Closed renal injury is usually
extraperitoneal.
In young children who have very little extraperitoneal fat, the peritoneum,
which is closely applied to the kidney, can tear with the renal capsule,
leaking blood and urine into the peritoneum .
Clinical features :(pain, hematuria, meteorism)
Pain:
Superficial soft-tissue bruising can be absent but there is local pain and
tenderness.
Haematuria:
Haematuria is the sign of a damaged kidney but it may not appear until
some time after the injury. Profuse bleeding may cause clot colic. Life-
threatening haemorrhage is a serious risk in closed or open trauma to the
kidney and should prompt careful monitoring of vital signs and urgent
investigation.
Summary box 71.6
Severe delayed haematuria
Sudden profuse haematuria between the third day and the third week after
the accident in a patient who appears to be progressing well is caused by a
clot becoming dislodged.
Meteorism
Abdominal distension 24–48 hours after renal injury is probably a result of
retroperitoneal haematoma implicating splanchnic nerves .
Management and treatment:
General management:to save the life of the patient.
Local management:
1- Conservative :watchful treatment of closed renal trauma is usually
successful. The possibility of injury to other organs must be considered at an
early stage.
• Blood should be cross-matched for transfusion if there is evidence of
hypovolaemic shock or continuing haemorrhage.Intravenous access should
be established.
• The patient should stay in bed while there is macroscopic haematuria and
activity must be curtailed for a week after the urine clears.
• Morphine analgesia may be appropriate.
• Hourly pulse and blood pressure charts must be kept.
• Antibiotics should be given to prevent infection of the haematoma.
• Each sample of urine passed should be checked for haematuria and the
result charted.
• Intravenous urography (IVU) or contrast-enhanced CT should be
performed urgently to assess the damage to the kidney and to show that the
other kidney is normal.
• Blood should be sent for grouping and serum saved for crossmatching.
2-Surgical exploration
Surgical exploration is necessary in less than 10% of closed injuries.
Indication
a- if there are signs of progressive blood loss.
b- there is an expanding mass in the loin.
The aim is to stop bleeding while conserving as much renal tissue as
possible; a renal arteriogram performed preoperatively can be helpful in
framing a strategy for doing this.
The possibility of damage to other abdominal organs is checked during a
transperitoneal approach. Release of the tamponading effect of the perirenal
haematoma can result in massive haemorrhage and the surgeon must be fully
prepared for this. When the kidney is irretrievably ruptured or avulsed from
its pedicle, nephrectomy is the only course. Small tears can be sutured over a
haemostatic sponge or a piece of detached muscle. Large single rents in the
kidney are best dealt with by passing a tube nephrostomy through the defect
and suturing the renal tissue around it. If the laceration is confined to one
pole of the kidney, partial nephrectomy may be practicable.
When a solitary kidney is sufficiently damaged to need exploration,it must
be repaired. Failing this, the wound is packed firmly with gauze to stop the
bleeding in the hope that some renal function may be retained when the
ruptured kidney heals.
3- Embolisation: A radiologist may be able to stop the haemorrhage by
embolisation if a bleeding vessel can be identified.
Complications:
1-Heavy haematuria may lead to clot retention requiring bladder washout
through a catheter or a cystoscope.
2-Pararenal pseudohydronephrosis may occur over the course of a few
weeks after injury as a result of a combination of complete cortical tear and
ureteric obstruction caused by scarring.
3-Hypertension resulting from renal fibrosis may occur long after injury. It
is often refractory to medical treatment and nephrectomy may be necessary.
4-Post-traumatic aneurysm of the renal artery is rare. There is pain in the
loin and a non-tender swelling may be felt if the aneurysm is large.
Congestion of the parenchyma leads to intermittent haematuria. Aortography
is diagnostic. Excision or nephrectomy is urgently indicated to prevent fatal
rupture of the aneurysm.
Summary box 71.8
Summary box 71.7