Trauma Nephrectomy Research Articles

Nephrectomy Is Not Associated with Increased Risk of Mortality or Acute Kidney Injury after High-Grade Renal Trauma: A Propensity Score Analysis of the Trauma Quality Improvement Program (TQIP).

Patients with high-grade renal trauma (HGRT) undergoing nephrectomy may be at higher risk for mortality compared to those treated conservatively. However, no study has controlled for degree of hemorrhage as a measure of shock. We hypothesized that after controlling for blood transfusions and other factors, nephrectomy after HGRT would be associated with increased mortality and acute kidney injury (AKI). We identified adult patients with HGRT (American Association for the Surgery of Trauma grade III-V) in TQIP (2013-2017). Propensity scoring was used to adjust for the probability of nephrectomy. Conditional logistic regression was used to analyze the association between nephrectomy and mortality and AKI. We adjusted for patient characteristics, injury specifics, and physiological factors including blood transfusions. There were 12,780 patients with HGRT, and 1,014 (7.9%) underwent nephrectomy. Mortality was 10.6% and 4.2% in the nephrectomy and nonnephrectomy groups, respectively (p <0.001). In nephrectomy patients, 8.6% experienced AKI vs 2.4% of nonnephrectomy patients (p <0.001). In the adjusted analysis, there was no association between nephrectomy and mortality (OR=0.367, 95% CI 0.09-1.497, p=0.162). There was also no association between nephrectomy and AKI. Increasing age, nonCaucasian race, increasing Injury Severity Score, decreasing Glasgow Coma Score and blood transfusions were associated with higher mortality. For AKI, independent predictors included increasing age, male sex, and blood transfusions. After adjusting for volume of blood transfused in the first 24 hours, nephrectomy after HGRT was not associated with increased mortality or AKI. As a clinical principle, trauma nephrectomy should be avoided when possible.

Outcome of angioembolization for blunt renal trauma in haemodynamically unstable patients: 10-year analysis of Queensland public hospitals.

The aim of the study was to evaluate whether angioembolization is an appropriate alternative method for the management of blunt renal trauma in haemodynamically unstable patients. A retrospective analysis was conducted from 2002 to 2012 at three tertiary trauma hospitals in the state of Queensland. Patients who had blunt renal trauma and underwent renal angioembolization or had a trauma nephrectomy were identified using patient records and operating theatre and interventional radiology databases. The inclusion criteria were - haemodynamically unstable patients with blunt renal trauma treated with angioembolization, above the age of 16 years. Patients who underwent angioembolization for other causes such as: penetrating renal trauma, post-procedure, renal tumours, renal angiomyolipomas or arteriovenous malformations were excluded. Patients below the age of 16 were also excluded. Post-embolization renal function, blood pressure, morbidity and mortality were analysed using the paired t2 test. A total of 668 renal trauma patients were identified during this period. Sixteen patients underwent angioembolization for blunt renal trauma. Post-procedure renal function normalized without any hypertension with the median follow up being 4 months. Four patients had post-embolization complications including a urinoma, two devascularized kidneys and one ureteric stricture requiring nephrectomy. There was no mortality. Selective angioembolization, where feasible, is an alternative method in the management of haemodynamically stable patients with blunt renal trauma maximizing nephron sparing and producing acceptable long-term outcomes with avoidance of the morbidity of trauma nephrectomy. This is the first study that we know of in Australia analysing the outcome of angioembolization for blunt renal trauma.

Renal artery embolisation immediately prior to emergency trauma nephrectomy

The aim of emergency nephrectomy in cases of blunt renal trauma is to control bleeding and so should not be delayed. We present a case of grade V blunt renal trauma where renal artery emoblisation (RAE) was used in the operating theatre immediately prior to trauma nephrectomy in order to control arterial haemorrhage. In this case, prior utilisation of RAE allowed the urologist to perform a standard approach to the renal pedicle by opening the retroperitoneal space. This is more routinely practiced and carries less risk of vascular mesenteric injury compared with the standard approach in trauma. Intra-operatively, there was minimal bleeding and the intra-vascular coils were easily ligated. Post operatively the patient avoids the sequelae of an ischaemic kidney associated with delayed interval nephrectomy.

Predicting surgical exploration in renal trauma

This study aimed to externally validate a previously described nomogram that predicts the need for renal exploration in the trauma setting. The predicted probability of nephrectomy was manually calculated using prospectively collected data from consecutive patients with renal trauma who presented to our institution between May 2001 and January 2010. To assess nomogram performance, receiver operating characteristic curves against the observed exploration rate were generated, and areas under the curve were calculated. Calibration curves were generated to assess performance across the range of predicted probabilities. Logistic regression modeling was used to determine clinical factors predicting exploration in a contemporary setting, and a nomogram was derived and internally validated using bootstrapping. The established nomogram was applied to the 320 patients who presented during the 9-year period. The global performance of the established nomogram was very high, with an area under the curve of 0.95. However, the model performance was poor for higher predicted probabilities, thus lacking predictive ability in the population where the model has the greatest potential utility. A clinical tool was generated to better predict trauma nephrectomy in our contemporary population, using platelet transfusion within the first 24 hours, blood urea nitrogen, hemoglobin, and heart rate on admission. The global accuracy for the new model was similar to the previous nomogram, but it was significantly better calibrated for patients with higher probabilities of nephrectomy, with good predictive accuracy even in patients with Grade 5 injuries. Older nomogram fails to accurately predict renal exploration in high-grade injuries in the contemporary setting. A new nomogram that more accurately predicts the need for exploration is presented. Therapeutic study, level IV; prognostic study, level III.

Death or Dialysis? the Risk of Dialysis-Dependent Chronic Renal Failure after Trauma Nephrectomy

Although renal trauma is increasingly managed nonoperatively, severe renovascular injuries occasionally require nephrectomy. Long-term outcomes after trauma nephrectomy are unknown. We hypothesized that the risk of end-stage renal disease (ESRD) is minimal after trauma nephrectomy. We conducted a retrospective review of the following: 1) our university-based, urban trauma center database; 2) the National Trauma Data Bank (NTDB); 3) the National Inpatient Sample (NIS); and 4) the U.S. Renal Data System (USRDS). Data were compiled to estimate the risk of ESRD after trauma nephrectomy in the United States. Of the 232 patients who sustained traumatic renal injuries at our institution from 1998 to 2007, 36 (16%) underwent a nephrectomy an average of approximately four nephrectomies per year. The NTDB reported 1780 trauma nephrectomies from 2002 to 2006, an average of 356 per year. The 2005 NIS data estimated that in the United States, over 20,000 nephrectomies are performed annually for renal cell carcinoma. The USRDS annual incidence of ESRD requiring hemodialysis is over 90,000, of which 0.1 per cent (100 per year) of renal failure is the result of traumatic or surgical loss of a kidney. Considering the large number of nephrectomies performed for cancer, we estimated the risk of trauma nephrectomy causing renal failure that requires dialysis to be 0.5 per cent. National data regarding the etiology of renal failure among patients with ESRD reveal a very low incidence of trauma nephrectomy (0.5%) as a cause; therefore, nephrectomy for trauma can be performed with little concern for long-term dialysis dependence.

Combined Splenectomy and Nephrectomy for Trauma: Morbidity, Mortality, and Outcomes Over 30 Years

: Spleen and kidney injuries carry mortality rates of 23% and 26%, respectively. When the magnitude of injury mandates simultaneous splenectomy and left nephrectomy, outcomes are unknown. The goals were to (1) identify the incidence of early morbidity and mortality among these patients and (2) compare these outcomes with those from the era preceding damage control and abdominal compartment syndrome therapies. : Injured patients who underwent a concurrent splenectomy and left nephrectomy at Grady Memorial Hospital (GMH, 1995-2007) were compared with those at Ben Taub (BT, 1978-1987). : Thirty-five and 30 patients underwent concurrent splenectomy and left nephrectomy at BT and GMH, respectively. Demographics, mortality (43% and 53%), and morbidity (79% and 81%) at BT and GMH were similar over a 3-decade span (p > 0.05). Deaths were typically due to refractory hemorrhage within 24 hours of admission to both centers (73% and 56%, p > 0.05). Despite advances in antimicrobials and drainage, 38% and 33% of patients developed a left subphrenic abscess. Associated injury pattern, splenic and renal injury grade, and blood loss were also consistent across centers (p > 0.05). More GMH patients presented with blunt mechanisms (33% vs. 14%) and associated injuries (4.1 vs. 2.4 per patient, p < 0.05). : The overall mortality associated with concurrent splenectomy and left nephrectomy approximates 43% to 53%. This has not changed despite a nearly 30-year timeframe and is still primarily related to refractory hemorrhagic shock. The complication rate of 80% is also consistent and is predominantly composed of left subphrenic abscesses and multiorgan failure.

The Morbidity of Trauma Nephrectomy

Mortality has been shown to be high in patients after trauma nephrectomy (TN). However, there are little data regarding morbidity in survivors. The objective of this study was to determine the morbidity rates associated with TN with attention directed to renal failure (RF) and formation of intra-abdominal abscess (IAA). Patients who underwent TN over a 9-year period (1996 to 2004) were identified from the trauma registry. Records were reviewed for all complications after TN in patients surviving at least 48 hours. Eighty-nine patients were identified with TN; 61 per cent resulted after penetrating trauma. Overall mortality was 34 per cent. Seventy-one patients survived greater than 48 hours; 51 (72%) experienced at least one morbidity. There was no difference in morbidity rates between patients undergoing blunt trauma and those undergoing penetrating trama. Patients with morbidities were significantly older, more severely injured, and had higher mortality rates and longer hospital courses. Infectious complications were seen in 52 per cent, respiratory in 48 per cent, gastrointestinal in 30 per cent, coagulopathy in 25 per cent, and RF and IAA were each seen in 14 per cent of patients. Patients undergoing TN are severely injured with significant morbidity. The results from this study allow us to establish benchmarks to assess complication rates for patients who undergo TN, which can provide prognostic information and goals to improve patient outcomes.

Does Nephrectomy for Trauma Increase the Risk of Renal Failure?

Renal failure is a feared complication following operations for severe trauma. Injuries to the kidney may be managed by nephrectomy or nephrorrhaphy. Nephrectomy may increase the risk of renal failure in already at-risk trauma patients. Nephrectomy for trauma should be avoided to the extent possible because it is associated with renal failure. From a prospectively collected trauma database, 59 patients with nephrectomy were matched at 1:1 ratio with 59 patients with nephrorrhaphy. Matching criteria were age (+/- 5 years), Injury Severity Score (+/- 3), abdominal Abbreviated Injury Score (+/- 1), and mechanism of injury (blunt or penetrating). The rates of renal function compromise (defined as a serum creatinine level >2 mg/dl for more than 2 days) and renal replacement therapy (continuous or intermittent) were compared in the two groups. The two groups were well-matched and similar with regard to injury severity and organs injured. Between nephrectomy and nephrorrhaphy patients, there were no differences in renal function compromise (10% vs. 14%, p = 0.57), renal replacement therapy (5% vs. 0%, p = 0.12), length of hospital stay (19 +/- 26 vs. 20 +/- 21, p = 0.8), and mortality (15% vs. 12%, p = 0.59). Salvaging the injured kidney does not seem to offer an obvious clinical benefit regarding postoperative renal function. Given the increased operative complexity of nephrorrhaphy in comparison to nephrectomy and the frequent need to abbreviate the operation in patients with severe trauma, nephrectomy should not be avoided when appropriate.

The role of nephrectomy in the acutely injured.

The high mortality in patients who undergo nephrectomy after trauma is not secondary to the nephrectomy itself but is the consequence of a more severe constellation of injuries associated with renal injuries that require operative intervention. A retrospective review of all patients identified using International Classification of Diseases, Ninth Revision codes as having sustained renal injuries over a 62-month period. Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. All medical records were reviewed for patient management, definitive care, and outcome. Based on outcome, patients were assigned to either the survivor or nonsurvivor group. For patients who underwent nephrectomy, intraoperative core temperature changes, estimated blood loss, and operative time were also reviewed. Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Twenty-nine patients underwent laparotomy with conservative management of the renal injury, of whom 5 (17.2%) died. Twelve patients had renal injuries repaired and all survived. Thirty-seven patients underwent nephrectomy, of whom 16 (43.2%) died. Compared with nephrectomy survivors, nephrectomy nonsurvivors had a significantly lower initial systolic blood pressure, higher Injury Severity Score, higher incidence of extra-abdominal injuries, shorter operative duration, and higher estimated operative blood loss. The nephrectomy survivors' core temperature increased a mean of 0.5 degrees C in the operating room, while the nephrectomy nonsurvivors' core temperature cooled a mean of 0.8 degrees C. Patients who undergo trauma nephrectomy tend to be severely injured and hemodynamically unstable and warrant nephrectomy as part of the damage control paradigm. That a high percentage of patients die after nephrectomy for trauma demonstrates the severity of the overall constellation of injury and is not a consequence of the nephrectomy itself.

Long-term effects of reduced renal mass in humans

The long-term risks of kidney donation have not been well defined. We carried out meta-analysis of investigations that examined the long-term effects of reduced renal mass in humans. We used multiple linear regression to combine studies and adjust for differences in the duration of follow-up, the reason for reduced renal mass, the type of controls, age and gender. We analyzed 48 studies with 3124 patients and 1703 controls. Unilateral nephrectomy caused a decrement in glomerular filtration rate (-17.1 ml/min; 95% confidence interval -20.2 to -14.0 ml/min) that tended to improve with each 10 years of follow-up (1.4 ml/min/decade; 0.3 to 2.4 ml/min/decade). Patients with single kidneys had small, progressive increases in proteinuria (76 mg/day/decade; 52 to 101 mg/day/decade), but proteinuria was negligible after nephrectomy for trauma or kidney donation. Nephrectomy did not affect the prevalence of hypertension, but there was a small increase in systolic blood pressure (2.4 mm Hg; -0.3 to 5.1 mm Hg, P > 0.05) which rose further with duration of follow-up (1.1 mm Hg/decade; 0.0 to 2.2 mm Hg/decade). Diastolic blood pressure was higher after nephrectomy (3.1 mm Hg; 1.8 to 4.4 mm Hg), but this increment did not change with duration of follow-up. Thus, in normal individuals, unilateral nephrectomy does not cause progressive renal dysfunction, but may be associated with a small increase in blood pressure.

Expression of tissue kallikrein in human kidney.

1. We studied the distribution of human tissue kallikrein mRNA in normal and diseased kidney, using in situ hybridization, together with immunohistochemical localization of renal kallikrein protein. Materials studied were (a) normal tissue from kidneys removed because of localized renal carcinoma, (b) kidneys removed because of post-traumatic haemorrhage and (c) renal biopsy specimens from patients with membranous glomerulonephritis and nephrotic syndrome. 2. A 1.35 kb EcoRI fragment of human tissue kallikrein cDNA was labelled with [32P]dCTP using the random-primer technique, and used for in situ hybridization. A specific rabbit antibody to active human urinary kallikrein was employed for immunocytochemistry, using a peroxidase-antiperoxidase method. 3. By in situ hybridization, no tissue kallikrein gene expression was seen in the carcinoma nephrectomy specimens. Positive expression was seen in the trauma nephrectomy tissue, and in four of five nephrotic syndrome biopsies. In all kidneys, expression was confined to the renal cortex. The dominant site of gene expression was the distal tubule. Apart from one area of positive signal related to an epithelial cell of Bowman's capsule, expression was not observed in glomeruli. Expression was also seen in the walls of large- and medium-sized blood vessels. 4. By immunohistochemistry, the dominant site of immunoreactivity was the distal tubule. Dense staining was also seen in granular peripolar cells and in isolated parietal epithelial cells close to the vascular pole. Isolated immunoreactive cells were seen in the media of large- and medium-sized arteries. 5. The tissue kallikrein gene in the kidney may not be constitutively expressed, but is expressed in response to physiological or pathological stimuli.(ABSTRACT TRUNCATED AT 250 WORDS)

Nephrectomy Following Trauma—Impact on Patient Outcome

Nephrectomy for trauma is done infrequently due to the success of renal sparing procedures. The purpose of this review was to quantitate the effect of nephrectomy on patient outcome. Over a 5-year period 55 of 783 patients had renal injuries confirmed at trauma laparotomy. Nephrectomy was performed in 14 (25%) of these patients. Thirteen patients had penetrating injuries (12 gunshot wounds, one stab wound) and one patient was the victim of blunt trauma. The average number of associated injuries was 3.6. Three patients exsanguinated intraoperatively. Renal failure (serum creatinine greater than 2.5 mg%) developed in four patients; three required hemodialysis. The average time of onset of renal dysfunction was 3 weeks, and in every case it was preceded by intra-abdominal sepsis. Two patients died, both from multiple organ failure, on postoperative day 25 and 26, respectively. In the seven patients free of renal failure, one patient developed sepsis and subsequently died. Of the eight surviving patients, all had adequate renal function as evidenced by an average blood urea nitrogen of 14 mg%, serum creatinine of 1.3 mg%, and a creatinine clearance of 77 ml/min. Renal failure following nephrectomy for trauma occurs late in the hospital course and is invariably preceded by sepsis. Nephrectomy is a marker of severe intra-abdominal injury, but in itself is not the major determinant of survival.