Original Investigation |

Successful Nonoperative Management of the Most Severe Blunt Renal Injuries:  A Multicenter Study of the Research Consortium of New England Centers for Trauma

Gwendolyn M. van der Wilden, MSc1; George C. Velmahos, MD, PhD1; D'Andrea K. Joseph, MD2; Lenworth Jacobs, MD2; M. George DeBusk, MD, MSc3; Charles A. Adams, MD3; Ronald Gross, MD4; Barbara Burkott, BSN4; Suresh Agarwal, MD5; Adrian A. Maung, MD6; Dirk C. Johnson, MD6; Jonathan Gates, MD7; Edward Kelly, MD7; Yvonne Michaud, RN, MSN7; William E. Charash, MD, PhD8; Robert J. Winchell, MD9; Steven E. Desjardins, RRT9; Michael S. Rosenblatt, MD10; Sanjay Gupta, MD11; Miguel Gaeta, MD12; Yuchiao Chang, PhD13; Marc A. de Moya, MD1
[+] Author Affiliations
1Department of Surgery, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
2Department of Surgery, Hartford Hospital, University of Connecticut School of Medicine, Hartford, Connecticut
3Department of Surgery, Rhode Island Hospital and Brown University, Providence, Rhode Island
4Department of Surgery, Baystate Medical Center, Springfield, Massachusetts
5Department of Surgery, Boston Medical Center and Boston University, Boston, Massachusetts
6Department of Surgery, Yale New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut
7Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
8Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont
9Department of Surgery, Maine Medical Center, Portland, Maine
10Department of Surgery, Lahey Clinic, Burlington, Massachusetts
11Department of Surgery, Southern New Hampshire Medical Center, Nashua, New Hampshire
12Department of Surgery, Elliot Hospital, Manchester, New Hampshire
13Department of Biostatistics, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
JAMA Surg. 2013;148(10):924-931. doi:10.1001/jamasurg.2013.2747.
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Importance  Severe renal injuries after blunt trauma cause diagnostic and therapeutic challenges for the treating clinicians. The need for an operative vs a nonoperative approach is debated.

Objective  To determine the rate, causes, predictors, and consequences of failure of nonoperative management (NOM) in grade IV and grade V blunt renal injuries (BRIs).

Design  Retrospective case series.

Setting  Twelve level I and II trauma centers in New England.

Participants  A total of 206 adult patients with a grade IV or V BRI who were admitted between January 1, 2000, and December 31, 2011.

Main Outcomes and Measures  Failure of NOM, defined as the need for a delayed operation or death due to renal-related complications during NOM.

Results  Of 206 patients, 52 (25.2%) were operated on immediately, and 154 (74.8%) were managed nonoperatively (with the assistance of angiographic embolization for 25 patients). Nonoperative management failed for 12 of the 154 patients (7.8%) and was related to kidney injury in 10 (6.5%). None of these 10 patients had complications because of the delay in BRI management. The mean (SD) time from admission to failure was 17.6 (27.4) hours (median time, 7.5 hours; range, 4.5-102 hours), and the cause was hemodynamic instability in 10 of the 12 patients (83.3%). Multivariate analysis identified 2 independent predictors of NOM failure: older than 55 years of age and a road traffic crash as the mechanism of injury. When both risk factors were present, NOM failure occurred for 27.3% of the patients; when both were absent, there were no NOM failures. Of the 142 patients successfully managed nonoperatively, 46 (32.4%) developed renal-related complications, including hematuria (24 patients), urinoma (15 patients), urinary tract infection (8 patients), renal failure (7 patients), and abscess (2 patients). These patients were managed successfully with no loss of renal units (ie, kidneys). The renal salvage rate was 76.2% for the entire population and 90.3% among patients selected for NOM.

Conclusions and Relevance  Hemodynamically stable patients with a grade IV or V BRI were safely managed nonoperatively. Nonoperative management failed for only 6.5% of patients owing to renal-related injuries, and three-fourths of the entire population retained their kidneys.

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