Conservative management of grade 5 renal injury: Case report

Abstract

Blunt trauma is a common cause of renal injuries, usually managed conservatively unless there’s hemodynamic instability, which warrants surgery. We present a case of a 22-year-old male with isolated Grade 5 renal injury, diagnosed via CT scan after blunt trauma. Despite the severity, he was successfully treated without surgery through conservative management in the ICU, with frequent monitoring and stabilization of his condition. While the best approach for hemodynamically stable Grade 5 renal injuries remains debated, our case suggests that conservative management is a viable option when patients are carefully monitored for any signs of instability.

1 Introduction

Renal trauma is rare and occurs in up to 5 % of all trauma patients and at in 10 % of patients with abdominal trauma. However, the kidneys are the most injured organ in the genitourinary system. . About 90 % of renal injuries are the result of blunt abdominal trauma, and only 2 % require surgical intervention. .

The organ injury severity scale developed by the American Association for the Surgery of Trauma (AAST) is the most widely used classification system for traumatic renal injuries. It classifies renal trauma from grade 1 to grade 5 (AAST). This system has been prospectively validated in several studies to predict clinical outcomes and the need for surgical interventions. .

More than 90 % of patients with renal trauma are generally managed conservatively. According to shared a report of Nerli et al. 69 out of 114 patients with grade 5 renal injury were managed non-operatively, only 8 of them needed delayed surgical exploration for both renal and non-renal indication. Moreovere, Van der Wilden et al. reported 154 of 206 patients with grade 4 and grade 5 blunt renal injury were managed non-operatively, which was successful for 142 of 154 patients (92.2 %), and failed for 12 patients (7.8 %) with no significant difference in failure between grade 4 and 5. In contrast, most patients with Grade 4 and 5 injuries usually present with associated major injuries and consequently may require surgical intervention. . However, the optimal management of isolated Grade 5 injuries in a hemodynamically stable patient remains controversial. .

Although embolization or open surgery may sometimes be required with interventional radiology particularly for severe cases. . Though there is limited evidence about the optimal management of grade 5 renal injuries, recent reports suggest conservative management can be considered as an alternative treatment option. . Here we report a case of Grade 5 renal injury successfully managed conservatively.

1.1 Case presentation

A 22-year-old male presented to the emergency department with a complaint of severe flank pain after sustaining blunt trauma to his left flank with a large water pipe.

On examination, the patient’s blood pressure was 80/40 mmHg and pulse rate was 100 beats per minute. Abdominal examination revealed ecchymosis and a tender, palpable left flank mass. The rest of the abdomen was soft and non-tender. Gross hematuria was noted during catheterization.

Immediate resuscitation was initiated with crystalloids, and a response in blood pressure to 100/70 mmHg was noted after administration of 3 L of normal saline. Laboratory examination indicated that the serum hematocrit was 48.8 %. Urinalysis showed +3 blood on dipstick.

CT scan of the abdomen and pelvis showed multiple lacerations of the left Kidney, including a mid-pole full-thickness laceration dividing the upper and lower segments with huge perirenal hematoma. These findings were consistent with Grade 5 renal injury (shattered Kidney) see Fig. 1 for details.

The patient was counselled about the options for treatment, and the informed decision was made to proceed with conservative management. He was also informed that operative intervention could be performed at any time during the observation if deemed necessary. He was admitted to the central ICU and was placed on close observation of vital signs and fluid balance. Serum hematocrit values were checked serially. The patient had episodes of hypotension, and his initial hematocrit dropped to 38.5 % at 12 hours. He was transfused with a total of 4 units of whole blood, and his hematocrit stabilized at 32.5 % after 48 hours of presentation. Afterwards, the patient remained hemodynamically stable with no additional problems and was discharged on the 7th day.

Follow-up visits at 2 and 6 weeks were uneventful. A Follow-up CT scan done at three months showed resolution of perirenal hematoma and fusion of the upper and lower segments with mild hydronephrosis of the upper segment. No extravasation of contrast was observed see Fig. 2 .

2 Discussion

Blunt traumas to the Kidney are more common, accounting for up to 90 % of renal injuries. Such injuries most commonly result from motor vehicle accidents. A direct blow to the flank or abdomen is another common cause. ^, . Parenchymal contusions or lacerations are the most common injuries, whereas renal vascular injuries occur in less than 5 % of blunt abdominal trauma. .

The presence of hematuria and hypotension are the two critical clinical signs suggestive of significant renal injury. Urinalysis showing >5 red blood cells per high power field, a positive urine dipstick, or gross hematuria raises the concern for renal injury. ^, . Nonetheless, it is important to note these findings are neither sensitive nor specific. Furthermore, there is a poor correlation between the severity of hematuria and the severity of renal injury. . Shariat et al. reported that hematuria was absent in 7 % of Grade 4 injuries.

CT scan remains the gold-standard imaging modality for evaluating renal trauma. . CT imaging is sensitive and specific for demonstrating parenchymal lacerations and urinary extravasations and for determining the size and location of surrounding retroperitoneal hematoma. . CT can also demonstrate concurrent intra-abdominal injuries to other organs and accurately identify and grade renal injury.

The AAST classifies renal injuries into five grades of severity based on the degree of laceration and vascular injury ( Table 1 ). , . Although the AAST system is primarily based on surgical findings, a CT scan demonstrates all the findings that correlate with surgical observations, providing the most definitive grading information. , .

Table 1

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