Abstract
Introduction
Pediatric blunt renal trauma (BRT) is rare but consumes substantial health care resources. Though evidence-based guidelines exist for pediatric blunt liver and spleen injuries, a lack of renal pathways results in variable, potentially unnecessary resource use. We hypothesized that management of low-grade pediatric BRT utilizes resources disproportionate to injury severity.
Methods
We retrospectively reviewed patients 1-17 years old admitted to a level 1 pediatric trauma center with BRT from 2014-2024. Injuries were classified using American Association for the Surgery of Trauma (AAST) guidelines as low-grade (LGI; I-III) or high-grade (HGI; IV-V). Demographic, injury, management, intervention, and outcome data were collected. Management variables included ICU admission, urinary catheterization, laboratory monitoring, activity restriction, and repeat imaging. Interventions included angioembolization, ureteral stenting, nephrectomy, and blood transfusion. Analyses were performed using Mann-Whitney U or Kruskal-Wallis tests for continuous and Chi-square or Fisher's exact tests for categorical variables. Data are presented as medians unless otherwise specified. Subset analysis was performed for patients with non-renal injuries increasing bleeding risk or ICU admission (complicating injuries).
Results
Fifty-six patients presented with BRT. Two were excluded for immediate operative management of complicating injuries. Of the remaining 54 patients, 38 (70%) had LGI and 16 (30%) had HGI. Groups did not differ in gender (66% vs 56% male), age (12 vs 10 years), or weight (44.3 vs 34.4 kg) (p>0.05). HGI patients had higher ISS (16.5 vs 9.5, p=0.011) and were more likely to have gross hematuria (94% vs 53%, p=0.004). Complicating injuries were present in 8 (21%) LGI and 1 (6%) HGI patient. Resource utilization was high, but less so for LGI than HGI patients. HGI patients were more likely to undergo urinary catheterization (50% vs 18%, p=0.018) and be admitted to the ICU (56% vs 26%, p=0.035). HGI patients had more hemoglobin draws (8 vs 4.5, p=0.012), more CT scans (2 vs 1, p0.001), longer total bedrest (3 vs 1 days, p=0.007), and longer lengths of stay (4 vs 3 days, p=0.007). Operative intervention was less common in LGI (0% vs 25%; p=0.006). All 4 operations were ureteral stent placements. No patients required nephrectomy or angiography. Blood transfusion rates were similar for LGI and HGI (5% vs 19%; p=0.15). All transfused LGI patients had complicating injuries; no uncomplicated LGI patient required intervention. Survival to discharge was similar between LGI and HGI (97% vs 100%). The only mortality was secondary to severe hypoxic brain injury.
Conclusion
BRT patients in our study had excellent outcomes and low rates of intervention. LGI patients required fewer resources and interventions than HGI patients, and uncomplicated LGI did not require intervention. Serial labs, ICU admission, inpatient observation, and bedrest remained high despite the absence of intervention, supporting de-escalation in this low-risk group.