Effect of renal angioembolization on post-traumatic acute kidney injury after high-grade renal trauma: A comparative study of 52 consecutive cases

doi:10.1016/j.injury.2013.11.030

Injury

Volume 45, Issue 5, May 2014, Pages 894-901

https://doi.org/10.1016/j.injury.2013.11.030 Get rights and content

Abstract

Background

Acute kidney injury (AKI) is associated with unfavourable outcomes and higher mortality after trauma. Renal angioembolization (RAE) has proved efficiency in the management of high-grade renal trauma (HGRT), but inevitably expose to unavoidable ischaemic areas or contrast medium nephrotoxicity which may impair renal function in the following hours. The aim of this study was to assess the potential acute impact of RAE on renal function in a consecutive series of HGRTs treated nonoperatively.

Materials and methods

Of 101 cases of renal trauma admitted to our Regional Trauma Center between January 2005 and January 2010, 52 cases of HGRT were treated nonoperatively; they were retrospectively classified into 2 groups according to whether RAE was used. Incidence and progression of AKI (RIFLE classification), maximum increase in serum creatinine (SCr), level since admission and recovery of renal function at discharge were compared between the groups. Multivariable analysis was performed to determine the role of RAE as an independent risk factor of AKI.

Results

RAE was performed in 10 patients within the first 48 h. The RAE and no RAE groups were comparable in terms of severity score, renal injury grade, and level of SCr on admission. AKI incidence (RIFLE score Risk or worse) after 48 and 96 h was 33% and 10%, respectively and did not differ significantly between groups at 48 h (p = 1.00) or 96 h (p = 1.00). The median maximum increase in SCr was significantly higher in no RAE than RAE group (30.4% vs. 6.9%, p = 0.04). RAE was not found to be a significant variable in a multiple linear regression analysis predicting maximum SCr rise (p = 0.34). SCr at discharge was >120% of baseline in only 5 patients, with no difference according to RAE (p = 0.24).

Conclusion

In a population of nonoperatively treated HGRT, the incidence of AKI decreased from almost 30% to 10% at 48 h and 96 h. RAE proceeding did not seem to affect significantly the occurrence and course of AKI or renal recovery. The decision to use RAE should probably not be restricted by fear of worsening renal function.

Section snippets

Background

After severe trauma, acute kidney injury (AKI) is a frequent and severe complication leading to increased morbidity and mortality [1], [2], [3]. Post-traumatic AKI is a complex disorder resulting from multiple risk factors such as age, injury severity, circulatory shock, rhabdomyolysis, abdominal trauma, or exposure to contrast medium [4], [5]. After renal trauma, additional risks have been identified due to direct parenchymal or vascular injuries [6]. It has been established that renal

Study design and patients

This retrospective study was performed in the Level I Regional Trauma Center of Lapeyronie Hospital (university institution in Montpellier, France). All patients diagnosed with a renal trauma on a computer tomography (CT) scan between January 2005 and January2010 were reviewed. Those with HGRT (defined by AAST OIS ≥3) initially treated by nonoperative management were included in this present study. We have reported previously our strategy of selective angiography using CT scan criteria in this

Population and initial management

Of 101 renal traumas admitted during the study period, 43 patients with AAST-OIS grade I and II renal traumas and 6 patients with HGRTs (4 nephrectomies, 1 nephrorrhaphy and 1 early death as a result of brain injury) were excluded. Finally, 52 patients with HGRT treated by nonoperative management were included in the present study. The main characteristics of the patients are summarized in Table 2. The mean age was 33.9 (SD 18.0) years, mean ISS was 22.7 (SD 15.5), and mean SAPS II was 22.2 (SD

Discussion

In the present study, we reviewed 52 consecutive cases of HGRT treated by nonoperative management; 10 patients benefited from RAE within the first 48 h depending on their clinical status and angiographic criteria. According to the RIFLE scoring system, AKI occurred in one-third of patients at 48 h and strongly regressed in most of the patients in the following days. At discharge, almost all patients recovered normal renal function; only 5 (10%) remained with a slightly increased SCr (125–165%

Conclusion

In our study of 52 consecutive patients with HGRT managed nonoperatively, AKI defined by a RIFLE stage of Risk or worse occurred in 30% of patients within the first 48 h and was still present in 10% of patients at 96 h. Despite unavoidable ischaemic areas or contrast medium toxicity, we found that performing RAE did noticeably influence neither the onset of AKI, nor renal recovery in the following days. Aware of the retrospective nature of the study and size of cohorts, our preliminary results

Conflict of interest

The authors have no conflict of interest to declare.

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The effect of transarterial embolization and nephrectomy on acute kidney injury in patients with blunt renal trauma: An American College of Surgeons - Trauma Quality Improvement Program analysis
2024, Injury
Transarterial embolization (TAE) or nephrectomy for patients with blunt renal trauma might result in acute kidney injury (AKI). Thus, we analyzed the American College of Surgeons - Trauma Quality Improvement Program (TQIP) to validate this. We hypothesized that nephrectomy, and not TAE, would be a risk factor for AKI in patients with blunt renal trauma.
Adult patients with blunt injuries from the TQIP between 2017 and 2019 were eligible for inclusion. The patients were divided into three treatment groups: conservative treatment, TAE, and nephrectomy. Multivariable logistic regression was used to clarify the AKI predictors.
The study included 12,843 patients, wherein 12,373 (96.3 %), 229 (1.8 %), and 241 (1.9 %) patients were in the conservative, TAE, and nephrectomy groups, respectively. A total of 269 (2.2 %), 20 (8.7 %), and 29 (12.0 %) patients had AKI in the three groups, respectively. Both TAE (odds ratio [OR], 2.367; 95 % confidence interval [CI], 1.372–3.900; p = 0.001) and Nephrectomy (OR, 2.745; 95 % CI, 1.629–4.528; p < 0.001) were a statistically significant predictor for AKI in the multivariable logistic regression.
TAE and nephrectomy were statistically associated with AKI in patients with blunt renal trauma. This result differs from our previous research findings that nephrectomy, but not TAE, was a risk factor for AKI in patients with blunt renal trauma. Further prospective and well-designed research may be needed.
Safety and efficacy of Endovascular Management of high-grade blunt renal injury
2022, Journal of Interventional Medicine
Citation Excerpt :
Renal failure was found in 1 patient with contralateral kidney hydronephrosis and in 1 patient with abnormal renal function before the intervention. Available evidence has also shown that kidney function after RAE is well preserved in patients.12,13, and 14 Collinset al. have reported either the onset of hypertension or worsening of preexisting hypertension in the follow-up of 6% of patients treated with RAE and they also reported that incomplete RAE or proximal embolization may induce distal ischemia, thereby resulting in an upregulation of the renin–angiotensin–aldosterone system and hypertension.14
To provide data on the safety and efficacy of renal arterial embolization (RAE) in patients with high-grade blunt renal injury.
Fifteen patients with high-grade blunt renal injury (AAST grades IV-V) admitted to our hospital from July 2014 to December 2019 were retrospectively reviewed in this study. Their clinical success rate and complications were investigated accordingly.
Fifteen patients with high-grade blunt renal injury, 13 men and 2 women with an average age of 41.6 years, including 11 hemodynamically unstable patients and 4 stable patients, were treated with RAE. Among these patients, 73.3% (11 of 15) had grade IV, and 26.7% (4 of 15) had grade V injuries, while 53.3% (8 of 15) patients had concomitant injuries. One patient received main RAE and 14 patients received selective RAE. The clinical success rate after the first embolization was 93.3% (14 of 15). RAE was repeated and was successfully performed in one patient with sustained hematuria. No significant difference in creatinine levels was found before and after embolization. During the follow-up period of 2–82 months, two patients required tube drainage due to urine leaks, one patient developed renal failure requiring renal replacement therapy, and one patient developed secondary hypertension.
RAE can provide a high success rate of hemostasis for both hemodynamically stable and unstable patients with high-grade blunt renal injury, and only minor complications are observed with this procedure.
Approach and Management of Traumatic Retroperitoneal Injuries
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Las lesiones traumáticas retroperitoneales constituyen un desafío para el cirujano de traumatología. Ocurren generalmente en el contexto de un paciente politraumatizado, con múltiples lesiones asociadas y en el que los procedimientos invasivos tienen un rol preponderante en el diagnóstico de estas lesiones. El retroperitoneo es la región anatómica que presenta mayores tasas de mortalidad, por lo que el diagnóstico precoz y tratamiento de estas lesiones adquiere especial relevancia. El objetivo de este trabajo es presentar la evidencia científica publicada hasta el momento en cuanto a su prevalencia, mecanismo lesional, métodos diagnósticos y tratamiento mediante una revisión de la literatura internacional de los últimos 70 años. Como conclusión, en esta revisión sistemática se pone de manifiesto una creciente tendencia al manejo no quirúrgico de las lesiones que afectan el retroperitoneo.
Traumatic retroperitoneal injuries constitute a challenge for trauma surgeons. They usually occur in the context of a trauma patient with multiple associated injuries, in whom invasive procedures have an important role in the diagnosis of these injuries. The retroperitoneum is the anatomical region with the highest mortality rates, therefore early diagnosis and treatment of these lesions acquire special relevance. The aim of this study is to present current published scientific evidence regarding incidence, mechanism of injury, diagnostic methods and treatment through a review of the international literature from the last 70 years. In conclusion, this systematic review showed an increasing trend towards non-surgical management of retroperitoneal injuries.
Angioembolization for solid organ injury: A brief review
2016, International Journal of Surgery
Citation Excerpt :
The lack of collateral blood flow puts the kidney at increased risk of segmental infarction and the risk of continued hemorrhage is described above. Saour et al. found that AE did not appear to affect the onset of acute kidney injury (AKI) or renal recovery following renal injury [48]. Angioembolization is a powerful option for patients who sustain solid organ injuries.
Non-operative management is the standard of care for blunt solid organ injuries in stable patients. Angioembolization is an important technique that improves success rates of non-operative management. We aimed to provide a brief review of the indications, effectiveness and complications associated with angioembolization for solid organ injuries.
We conducted a literature search of the PubMed database using the terms “trauma”, “angioembolization”, and “solid organ embolization” limited to studies published in the English language. Abstracts and full text were manually reviewed to identify suitable articles.
The current brief review is based on content from the more recently published articles related to angioembolization for solid organ injuries after trauma.
Angioembolization is appropriate for hemodynamically stable patients with contrast extravasation on CT scan or high-grade injury to a solid organ. Non-operative management success rates have improved with the adoption of angioembolization. The complications associated with angioembolization are acceptable in the context of avoiding a laparotomy, and are often related to the severity of the injury.
Angioembolization is a natural extension of the move towards non-operative management for solid organ injuries. Randomized controlled trials are required to fully characterize the indications and efficacy of its use.
Indications for embolization in a French level 1 trauma center
2016, Journal of Visceral Surgery
Citation Excerpt :
The main complication is the post-embolization syndrome associating pain and inflammatory syndrome, seen in 10% of cases [21]. The risk of contrast toxicity with the secondary risk of kidney failure should not contra-indicate embolization because the literature seems to indicate that angiography does not affect kidney function in these patients [24]. It is important to identify renal artery lesions, although they are very rare (0.05 to 0.08% of cases) and therefore not well recognized [25].
Abdominal trauma accounts for nearly 20% of all traumatic injuries. It often involves young patients sustaining multiple injuries, with a high associated mortality rate. Management should begin at the scene of injury and relies on a structured chain of care in order to transport the trauma patient to the appropriate hospital center. Management is multi-disciplinary, involving intensive care specialists, surgeons and radiologists. Imaging to precisely define injury is best performed with whole body dual phase computed tomography, which can also identify the source of bleeding. Non-operative management has developed considerably over the years: this includes selective embolization in case of active bleeding or vascular anomalies in stable or stabilized patients after resuscitation. Embolization has become one of the corner stones of abdominal trauma management and interventional radiologists must play an active role on the trauma team. This overview details the different embolization procedures according to the involved organ and embolic agent used.
Place of embolization for trauma patient in a French level 1 trauma center
2016, Journal de Chirurgie Viscerale
Les traumatismes abdominaux représentent jusqu’à 20 % des traumatismes et concernent souvent des patients jeunes polytraumatisés avec une mortalité élevée. Leur prise en charge débute dès les lieux de l’accident avec la nécessité de mettre en place des réseaux de soin pour orienter au mieux les patients vers les centres de référence en fonction de la gravité de leur traumatisme. Cette prise en charge doit être multidisciplinaire entre les réanimateurs, les chirurgiens et les radiologues. Le bilan lésionnel doit être au maximum réalisé par un scanner corps entier avec un temps artériel et veineux. Ce scanner permet d’évaluer précisément la source du saignement chez les patients avec une hémorragie. Les traitements non opératoires se sont énormément développés ces dernières années avec la possibilité de réaliser des embolisations sélectives en cas de saignement actif ou de malformation vasculaire chez les patients stables et stabilisés. L’embolisation est devenue une pierre angulaire de la prise en charge des patients avec un traumatisme abdominal et le radiologue interventionnel doit faire partie des équipes confrontées à ces patients. Cette mise au point détaillera les différentes procédures endovasculaires en fonctions des organes lésés et du matériel utilisé.
Abdominal traumas account for nearly 20% of all traumas. They often involve young polytrauma patient with a high mortality rate. Injury management must begin at the scene of the trauma and depend on a structured chain of care in order to admit trauma patient to the most suitable center. This management must be multidisciplinary between intensive care specialists, surgeons and radiologists. A precise work up of the lesions must be done by a whole body computed tomography with an arterial and venous phase. It helps to precisely identify the source of bleeding in case of hemorragia. Non-operative management has developed considerably over the years with the possibility of using selective embolization in case of active bleeding or vascular anomaly in stable patients with or without resuscitation. Embolization has become one of the corner stones of abdominal trauma management and interventionalists must be integrated in the trauma team. This overview will precise the different embolization procedures depending on the affected organ and embolic agent used.

View all citing articles on Scopus

View full text

Effect of renal angioembolization on post-traumatic acute kidney injury after high-grade renal trauma: A comparative study of 52 consecutive cases

Abstract

Background

Materials and methods

Results

Conclusion

Section snippets

Background

Study design and patients

Population and initial management

Discussion

Conclusion

Conflict of interest

J Pediatr Surg

J Urol

Urology

J Am Coll Surg

Am J Surg

Eur J Vasc Endovasc Surg

J Am Coll Cardiol

A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients

Nephrol Dial Transplant

Redefining renal dysfunction in trauma: implementation of the Acute Kidney Injury Network staging system

J Trauma

Natural history and impact on outcomes of acute kidney injury in patients with road traffic injury

Clin Nephrol

Acute kidney injury after trauma: prevalence, clinical characteristics and RIFLE classification

Indian J Crit Care Med

Risk factors for acute renal failure in trauma patients

Intensive Care Med

Emergency department hypotension is not an independent risk factor for post-traumatic acute renal dysfunction

J Trauma

Organ injury scaling: spleen, liver, and kidney

J Trauma

American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy, dialysis, and death in patients with blunt injury and nephrectomy for penetrating injuries

J Trauma

What are the specific computed tomography scan criteria that can predict or exclude the need for renal angioembolization after high-grade renal trauma in a conservative management strategy?

J Trauma

The role of interventional radiology in the management of blunt renal injury: a practical protocol

J Trauma

Long-term functional and morphological effects of transcatheter arterial embolization of traumatic renal vascular injury

BJU Int

Late evaluation of the relationship between morphological and functional renal changes and hypertension after non-operative treatment of high-grade renal injuries

World J Emerg Surg