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5 Grading ofRenal Trauma
(Glasgow Coma Scale score2≤8), acidosis (base decit ≤−6.0), coagulopathy
(PTT≥40s or INR≥1.4), and age (≥70years) [2].
The BPD was subsequently validated by many studies including a recent Dutch
observational study [7]. Well before a consensus was reached to dene polytrauma,
its physiopathology was intensively studied, and Gebhard and Huber-Lang proposed the following critical events [1]:
– Danger-sensing molecules phase: coagulation cascade, kallikrein-kinin system,
complement system, acute phase reaction
– Trauma-induced complementopathy
– Trauma-induced intravascular coagulopathy (TIC)
– Trauma-induced neuroinammation
In 1974, Baker etal. introduced a method for describing patients presenting with
multiple injuries to evaluate their prognosis and emergency priorities: The Injury
Severity Score (ISS), which was developed from the Abbreviated Injury Scale
(AIS) [8]. They dened the ISS as the sum of the squares of the highest AIS grade
in each of the three most severely injured areas, with the purpose of dramatically
increasing the correlation between the severity of the injury and the mortality, compared with the AIS.
2
Glasgow Coma Score (GCS) [5, 6]:
Parameters:
Best eye response (4 points)
– No eye opening: 1
– Eye opening to pain: 2
– Eye opening to sound: 3
– Eyes open spontaneously: 4
Best verbal response (5 points)
– No verbal response: 1
– Incomprehensible sounds: 2
– Inappropriate words: 3
– Confused: 4
– Orientated: 5
Best motor response (6 points)
– No motor response: 1
– Abnormal extension to pain: 2
– Abnormal exion to pain: 3
– Withdrawal from pain: 4
– Localizing pain: 5
– Obeys commands: 6
Total score:
GCS 3–8: severe
GCS 9–12: moderate
GCS 13–15: mild
5 Grading ofRenal Trauma
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The ISS is allocated a marking from 0 to 75 and correlates linearly with mortality, morbidity, and hospital stay. The ISS has been validated and categorized as follows [9]:
• <9=Mild
• 9–15=Moderate
• 16–24=Severe
• ≥25=Profound
Therefore, major trauma is dened by ISS >15.
Progressing further in our discussion, it is important to avoid confusing kidney
trauma with acute renal injury (AKI), and a bracket is opened in the following
paragraphs to elucidate this concept. AKI is dened as a sudden loss of kidney function arising from multiple causes such as sepsis, hypovolemic shock, drugs, and so
on. AKI may develop in a polytrauma patient with or without a direct physical hit to
the kidneys. According to the Kidney Disease Improving Global Guidelines
(KDIGO), AKI has three stages and is dened by any of the following: an increase
in serum creatinine (SCr) by ≥0.3mg/dL (≥26.5μmol/L) within 48h; or an increase
in SCr to ≥1.5 times baseline, which is known or presumed to have occurred within
the prior 7days; urine volume≤0.5mL/kg/h for 6h [10]. The duration of AKI is
limited to 7days. Beyond this limit, the pathology will be called acute kidney disease or disorder, and if persisting for more than 3months, the term will change to
chronic kidney disease [11].
Following polytrauma, AKI is triggered by massive hemorrhage, systemic
inammatory response syndrome (SIRS), and multiple-organ dysfunction syndrome (MODS). Two or more criteria have to be fullled to dene a SIRS:
Temperature>38.8 or<36°C, tachycardia >90 beats/min, tachypnea >20breaths/
min or PaCO2 <32mmHg, leukocytes >12,000/mm3 or leukopenia <4000/mm3,
or>10% immature neutrophils [12].
AKI associated with trauma has a high mortality rate (28.08%) [13]. Severe AKI
was found in 2.3% of 64,059 civilians with gunshot wounds and 0.9% required
dialysis. It was associated with older age, male sex, history of diabetes or hypertension, hypotension at presentation (systolic blood pressure<90mmHg), coagulopathy, lower Glasgow Coma Scale score, sepsis, hollow viscus injury, and higher
injury severity score. The likelihood for patients with severe AKI to die was twice
as high as that of patients without severe AKI, and it was even higher for those
requiring dialysis as 28.4% of the latter group died [13, 14].
AKI might also develop in the context of isolated brain injury, as shown by a
study recruiting 37,851 patients with isolated severe traumatic brain injuries, of
whom 2.1% experienced severe (stage 3 or greater) AKI [15].
In developing countries, the risk of mortality for motor trafc accidents is far
higher than in developed countries [16], and the polytrauma victims are younger,
with a higher male predominance (92.3%) and a higher percentage (38.5%) of
AKI [17].
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Table 5.1 Kidney injury scale (from Moore etal. [18], with permission from Elsevier)
a
Type Injury description
Grade
I Contusion Microscopic or gross hematoma, urologic studies normal 2
Hematoma Subcapsular, nonexpanding without parenchymal laceration 2
II Hematoma Nonexpanding perineal hematoma conned to renal
retroperitoneum
Laceration <1.0cm parenchymal depth of renal cortex without urinary
III Laceration >1.0cm parenchymal depth of renal cortex without collecting
IV Laceration Parenchymal laceration extending through the renal cortex,
Vascular Main renal artery or vein injury with contained hemorrhage 4
V Laceration Completed shattered kidney 5
Vascular Avulsion of renal hilum which devascularizes the kidney 5
a
Advance one grade for bilateral injuries up to grade III
extravasation
system rupture or urinary extravasation
medulla, and collecting system
5 Grading ofRenal Trauma
AIS90
2
2
3
4
In summary, AKI is far more frequent than direct kidney trauma and its presence
portends a more serious prognosis. It can be associated or not with gross kidney
trauma. It is important to remember that AKI per se is not a surgical pathology and
is better managed by nephrologists and acute medicine specialists in a high dependency or an Intensive Care Unit, and the management is based on the treatment of
the primary insult and control of systemic disorders and also short-term hemodialysis if required until the acute episode is over, and the kidneys recover.
After clarifying this potential source of confusion, let us close the bracket and get
back to the grading of the kidney trauma.
The American Association for the Surgery of Trauma (AAST) grading score of
kidney trauma was introduced by Moore etal. in 1989 (Table5.1) [18].
This grading system has been validated by many studies: After a review of 54,148
entries containing the AIS-coded injuries in the National Trauma Data Bank
(NTDB), Tinkoff et al. found that, in the 35,897 isolated abdominal solid organ
injuries (including spleen, liver, and kidney), the outcome corresponded to the
increase of injury grade [19]. And a monocentric retrospective review of 2467
patients with renal trauma showed a linear correlation between the AAST grades
and the need for surgical exploration in general and for nephrectomy in particular
[20] (Fig.5.1).
In a large proportion of patients with blunt as well as penetrating renal injury,
the need for nephrectomy and the overall outcome can be reliably predicted by a
combination of the AAST grade of renal injury, the overall injury severity score,
and the requirement of blood transfusion [21]. However, concerns were raised
about the lack of clarication of certain subtypes of injuries within grades IV and
V [22], and proposals were made in 2011 concerning segmental vascular injuries
and ureteral pelvic injuries [23]. In 2018, the AAST Patient Assessment Committee
revised the kidney AAST grading system to include vascular thrombosis, segmental renal artery or vein injury, and all collecting system injuries as grade IV
5 Grading ofRenal Trauma
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45
injuries, and a devascularized kidney with active bleeding as grade V kidney
injury [24]. In 2019, the American Society of Emergency Radiology adapted the
description of CT ndings in accordance with the above updated AAST revision
and highlighted important differences from the prior grading scheme [25]
(Table5.2 and Fig.5.2).
Fig. 5.1 Correlation between treatment and AAST grade. (From Santucci RA, etal. [20], with
permission from Wolters Kluwer Health)
Table 5.2
The last column emphasizes the new elements in the revised grading scheme (from Chien LC etal.
[25], with permission from Springer Nature)
AAST
grade
I
II
III
Description of CT features associated with each AAST OIS grade in the 2018 revision.
CT criteria in the revised grading
system
– Isolated parenchymal contusion
– Subcapsular hematoma
– Renal parenchymal laceration
≤1cm in depth without extension to
the collecting system
– Perirenal hematoma contained by
Gerota fascia
– Renal parenchymal laceration
>1cm without extension to the
collecting system
– Any low-grade injury with
associated vascular injury or active
bleeding contained by Gerota fascia
New features in the revised grading system
– Removes microscopic or macroscopic
hematuria without imaging abnormality
– Removes term nonexpanding from
subcapsular hematoma
– Removes term nonexpanding from
perirenal hematoma
– Adds vascular injury, dened as AVF or
pseudoaneurysm
– Includes active bleeding within Gerota
fascia
(continued)
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Table 5.2 (continued)
AAST
grade
IV
V
CT criteria in the revised grading
system
– Parenchymal laceration extending to
the collecting system
– Renal pelvis laceration or complete
ureteropelvic laceration
– Segmental renal artery or vein
intimal injury/thrombus
– Active bleeding beyond Gerota
fascia into the retroperitoneum or
peritoneum
– Segmental or complete renal
infarction due to vessel thrombosis
in the absence of active bleeding
– Main renal artery or vein laceration
or avulsion from the renal hilum
– Complete organ devascularization
with active bleeding
– Shattered kidney
5 Grading ofRenal Trauma
New features in the revised grading system
– Incorporates isolated renal collecting
system injury
– Includes active bleeding beyond Gerota
fascia
– Removes bleeding injuries to the main
renal artery and vein (laceration or
avulsion of hilar vessels now included in
grade V)
– Adds active bleeding in setting of
complete renal infarction in distinction
from grade IV
Fig. 5.2
The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS)
for the kidney (2018 revision): Normal anatomy: for illustrative purposes only, the renal vein has
been removed. Grade I: (a) subcapsular hematoma and/or (b) parenchymal contusion without laceration. Grade II: (a) perirenal hematoma conned to Gerota fascia and (b) renal parenchymal
laceration ≤1cm in depth without urinary extravasation. Grade III: (a) renal parenchymal laceration >1cm in depth without urinary extravasation; (b) active bleeding arising from the kidney and
contained by Gerota fascia; and (c) pseudoaneurysm (PSA)/arteriovenous stula (AVF) arising
from the kidney and contained by Gerota fascia. Grade IV: (a) parenchymal laceration extending
into the urinary collecting system with urinary extravasation; (b) renal pelvis laceration (illustrated) and/or complete ureteropelvic disruption; (c) segmental renal vein or artery PSA/AVF; (d)
active bleeding extending beyond Gerota fascia into the retroperitoneum or peritoneal cavity; and
(e) segmental or complete kidney infarction due to vessel thrombosis without active bleeding (note
that only segmental artery thrombosis and infarction are illustrated). Grade V: shattered kidney
with loss of identiable parenchymal renal anatomy; devascularized kidney (a) with (b) active
bleeding; main renal artery or vein laceration or avulsion of the hilum (main renal artery laceration
illustrated in (b)). (© 2019 Mica Duran. From Chien LC et al. [25], with permission from
Springer Nature)
475 Grading ofRenal Trauma
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5 Grading ofRenal Trauma
Patients who are victims of gunshot kidney injury have higher grades than those
assaulted by stabbing, and the latter group sustains higher injury grades than those
who suffer blunt trauma [26]. The AAST grade has a statistically signicant correlation with the need for surgery and for the risk of nephrectomy; 86–91% of patients
undergoing exploration for grade V ultimately have nephrectomy vs only 9% for
grade IV [22, 25, 27] (Fig.5.3). These results are sufcient to emphasize the impor-
tance of a careful distinction between grades IV and V before venturing into a surgical exploration.
The World Society of Emergency Surgery (WSES) has adapted the AAST grading to the patient’s hemodynamical condition and proposed four grades grouped
into three categories: minor, moderate, and severe [28] (Table5.3).
A different grading system (the Chatelain Classication) has been used in the
French medical literature since 1981 but is almost abandoned now. It comprised
four grades only and was based on intravenous urography (IVU) ndings, hence its
weakness. To date, the original AAST classication still holds the lion’s share
among trauma doctors, clinicians, and researchers.
ab c
Fig. 5.3 AAST grade V injury in two separate patients. (a) Sagittal CECT of a patient with tran-
sected kidney demonstrates complete devascularization of the interpolar region of the right kidney.
(b) Intraoperative photograph of the same patient as (a) demonstrating transection of the kidney,
with a small superior pole attached to the IVC (arrow), which was subsequently repaired. The
inferior pole is in the lower-left corner (star). No distinct arterial supply to the inferior pole could
be identied. Superior pole parenchyma was well-vascularized but was avulsed from the entire
collecting system. Nephrectomy was performed. (c) Coronal CECT in a separate patient. (From
Chien LC etal. [25], with permission from Springer Nature)
Table 5.3 WSES kidney trauma classication (from Coccolini, F. etal. [28]. Creative Commons
Attribution 4.0 International License)
WSES grade AAST
Minor WSES grade I I–II Stable
Moderate WSES grade II III or segmental vascular injuries Stable
Severe WSES grade III IV–V or any grade parenchymal lesion
WSES grade IV Any Unstable
Hemodynamic
Stable
with main vessel dissection/occlusion
References
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5 Grading ofRenal Trauma
Symptoms, Signs, andDiagnostic Means
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ofRenal Trauma
6.1 Presentation andPhysical Examination
Generally, the patient is brought to the hospital by relatives or by an ambulance
from the accident (RTA, sports trauma, and fall) or the aggression scene, and history
is readily provided by the patient himself if fully conscious, the rescuers, the relatives, or the bystanders. Usually, the mechanism of the injury is obvious. The rst
step is to assess his consciousness and hemodynamic status. Vital signs must be
taken immediately, and the patient kept under monitoring (BP, pulse, RR, and O2
saturation) and instructed on strict bed rest until denitely labeled as stable with
minor trauma. Patients might present with anemia and hemodynamic instability
(i.e., systolic blood pressure<90mmHg). Patients who sustained penetrating renal
injury are more likely to present with hemodynamic instability than those with blunt
trauma in a proportion of 14.2% vs. 8.36%, respectively [1].
The patient can also present with loin or ank pain with or without hematuria.
The presence of hematuria is an important positive nding, but its absence does not
exclude renal trauma, and its importance does not correlate with the grade of the
trauma. The physical examination will show bruising, ecchymosis, swelling, and
tenderness at the loin, ank, or abdominal region. In penetrating injuries, the wound
caused by the stabbing instrument will be obvious, and the entry and possibly the
exit site of the bullet in a gunshot injury should also be determined. Signs of peritonitis might be observed if a hollow viscus has been perforated.
As renal trauma might present in the context of multiorgan injury, a general
physical examination is of paramount importance to avoid missing injuries of other
organs: in addition to the urgent consciousness and hemodynamical status assessment already mentioned above, the examination should rule out rib fracture or spine
injury, hemoperitoneum (spleen or liver rupture), hemo- or pneumothorax (pleural
or broncho-pulmonary injury), and peritonitis (injury of hollow abdominal viscera:
colon, small bowel, stomach, etc.).
6
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_6
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