NESS - Successful Non-operative Management Of The Most Severe Blunt Renal Injuries: A Multicenter Study Of The Research Consortium Of New England Centers For Trauma (ReCONECT)

Successful Non-operative Management Of The Most Severe Blunt Renal Injuries: A Multicenter Study Of The Research Consortium Of New England Centers For Trauma (ReCONECT)
*Gwendolyn M van der Wilden¹, George C Velmahos¹, *D'Andrea K Joseph², Lenworth Jacobs², *M. George DeBusk³, Charles A. Adams³, Ronald Gross⁴, *Barbara Burkott⁴, Suresh Agarwal⁵, *Adrian A. Maung⁶, *Dirk C Johnson⁶, Jonathan Gates⁷, Edward Kelly⁷, *Yvonne Michaud⁷, William E Charash⁸, Robert J Winchell⁹, *Steven E Desjardins⁹, Michael S. Rosenblatt¹⁰, *Sanjay Gupta¹¹, *Miguel Gaeta¹², *Yuchiao Chang¹, *Marc A de Moya¹
¹Massachusetts General Hospital, Boston, MA;²Hartford Hospital, Hartford, CT;³Rhode Island Hospital, Providence, RI;⁴Baystate Medical Center, Springfield, MA;⁵Boston Medical Center, Boston, MA;⁶Yale New Haven Hospital, New Haven, CT;⁷Brigham and Womens Hospital, Boston, MA;⁸University of Vermont, College of Medicine, Burlington, VT;⁹Maine Medical Center, Portland, ME;¹⁰Lahey Clinic, Burlington, MA;¹¹Southern New Hampshire Medical Center, Nashua, NH;¹²Elliot Hospital, Manchester, NH

Objective: To determine the rate, causes, predictors, and consequences of failure of non-operative management (NOM) in grade IV and V blunt renal injuries (BRI).
Design: Retrospective case series.
Setting: Twelve trauma centers in New England Patients: 209 adult patients with a grade IV or V BRI who where admitted between January 1, 2000, and December 31, 2011. Main Outcome Measures: Failure of NOM, defined as the need for delayed operation.
Results: 52 patients (25%) were operated on immediately and 157 (75%) were managed non-operatively (with the assistance of angiographic embolization in 26 patients). NOM failed in 13 patients (8%) and was related to kidney injury in 11 (7%), who underwent a (partial) nephrectomy. None of these 11 patients suffered complications because of delay in BRI management. The time from admission to failure was 0.9+0.9 days (range: 1 to 4), and the cause was hemodynamic instability in all cases. Multivariate analysis identified 2 independent predictors of NOM failure: Age > 55 years and road traffic crash as mechanism of injury. When both risk factors were present, NOM failure occurred in 30% of patients; when both were absent, there were no NOM failures. Among patients successfully managed by NOM, 40 (28%) developed renal-related complications, including hematuria (22), urinoma (12), urinary tract infection (8), renal failure (7), and abscess (1). These were all managed successfully. The renal salvage rate was 79% for the entire population, and 94% among patients selected for NOM.
Conclusions: Hemodynamically stable patients with grade IV and V BRI were safely managed by NOM. Only 8% failed NOM and three fourths of the entire population retained their kidneys.

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