Abstract
ObjectiveTo evaluate the anatomical and functional renal alterations and the association with post-traumatic arterial hypertension.MethodsThe studied population included patients who sustained high grades renal injury (grades III to V) successfully non-operative management after staging by computed tomography over a 16-year period. Beyond the review of medical records, these patients were invited to the following protocol: clinical and laboratory evaluation, abdominal computed tomography, magnetic resonance angiography, DMSA renal scintigraphy, and ambulatory blood pressure monitoring. The hypertensive patients also were submitted to dynamic renal scintigraphy (99mTc EC), using captopril stimulation to verify renal vascular etiology.ResultsOf the 31 patients, there were thirteen grade III, sixteen grade IV (nine lacerations, and seven vascular lesions), and two grade V injuries. All the patients were asymptomatic and an average follow up post-injury of 6.4 years. None had abnormal BUN or seric creatinine. The percentage of renal volume reduction correlates with the severity as defined by OIS. There was no evidence of renal artery stenosis in Magnetic Resonance angiography (MRA). DMSA scanning demonstrated a decline in percentage of total renal function corresponding to injury severity (42.2 ± 5.5% for grade III, 35.3 ± 12.8% for grade IV, 13.5 ± 19.1 for grade V). Six patients (19.4%) had severe compromised function (< 30%). There was statistically significant difference in the decrease in renal function between parenchymal and vascular causes for grade IV injuries (p < 0.001). The 24-hour ambulatory blood pressure monitoring detected nine patients (29%) with post-traumatic hypertension. All the patients were male, mean 35.6 years, 77.8 % had a familial history of arterial hypertension, 66.7% had grade III renal injury, and average post-injury time was 7.8 years. Seven patients had negative captopril renography.ConclusionsLate results of renal function after conservative treatment of high grades renal injuries are favorable, except for patients with grades IV with vascular injuries and grade V renal injuries. Moreover, arterial hypertension does not correlate with the grade of renal injury or reduction of renal function.
Highlights
The non-surgical management of high-grade renal injuries is initially successful in more than 85% of patients [1,2,3]
There was no correlation between a serious reduction of renal function found by dimercaptosuccinic acid (DMSA) renal scintigraphy and the presence of arterial hypertension
The long-term follow-up showed 29% of the patients were hypertensive without direct correlation with the grade of renal injury or serious reduction of renal function found by DMSA renal scintigraphy
Summary
The non-surgical management of high-grade renal injuries is initially successful in more than 85% of patients [1,2,3]. The Organ Injury Scale (OIS) of the American Association for the Surgery of Trauma (AAST) is of utmost clinical importance since the higher the renal injury grade with the higher the frequency of surgery [4]. The primary objective of the non-surgical treatment is to preserve enough renal parenchyma to prevent dialysis in the case of loss of the contralateral kidney (to achieve approximately 30% function of a normal kidney) [5,6,7,8,9]. Posttraumatic renovascular hypertension is usually renin dependent, and associated with vascular and renal parenchymal injury [18,20]. Captopril renography is a useful and reliable test in patients with suspicion of renovascular hypertension [21,22]
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