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Contemporary Management of Pediatric Renal Injuries at a Level 1 Trauma Center
Zachary Ballinger MD1, *Jahnavi Challagonda 2, Muriel A. Cleary MD3, Jonathan Green MD, MSCI3, Kaitlyn Wong MD, PhD3, Jeremy T. Aidlen MD3
1Surgery, UMass Chan Medical School, Worcester, MA; 2UMass Chan Medical School, Worcester, MA; 3Pediatric Surgery, UMass Memorial Medical Center, Worcester, MA

Background:
Renal trauma is the most common cause of urinary tract injury in the pediatric population, with blunt injury mechanisms comprising the overwhelming majority of cases. Management strategies for renal injury have trended towards minimally invasive, with current guidelines recommending non-operative management and angio-embolization for high grade injuries in hemodynamically stable patients. However, many have advocated for avoidance of angio-embolization, instead promoting permissive hypotension and close monitoring. This study aimed to examine demographics and contemporary management of patients with traumatic renal injury at a Level 1 Pediatric trauma center.
Study Design:
A retrospective review of all-cause trauma patients admitted to UMass Memorial Medical Center from 2016-2023 was conducted. Patients <18 years old admitted with an acute traumatic kidney injury were identified by ICD-10 codes. Any patient without radiographic evidence of AAST Kidney Injury was subsequently excluded. Demographic and key clinical characteristics were obtained and analyzed.
Results:
From 2016-2023, 2342 pediatric trauma patients were admitted, of which 29 had radiographically confirmed acute traumatic renal injuries (1.24%). See Table 1 for demographic information. ISS at presentation averaged 16 (95% CI: -8.4 - 40.1) while average kidney injury grade was 2.5 (95% CI: 0 - 5). 48% of patients received a urology consultation, though only 10% had collecting system injuries. There were no nephrectomies during this time period, no angio-embolization, 2 ureteral stents placed, and 1 percutaneous nephrostomy tube placed. Splenic lacerations (28%), spine fractures (28%), liver lacerations (21%), and rib fractures (21%) were the most common concomitant injuries, and 4 1% of patients required surgical intervention on other organ systems while admitted. There were no documented complications related to a patient’s kidney injuries, though one patient did have Page kidney that requires ongoing care. Multivariate regression demonstrated increased odds of prolonged ICU stay and increased Bed Rest Days with increased Kidney injury grade, after adjustment for demographic indices, age, race, and injury cause (aOR 4.25 and 4.65, respectively). ISS correlated linearly with increased Bed Rest Days after similar multivariate adjustment (adjusted slope 0.12, R squared 0.2), but not increased ICU days.
Conclusions:
Traumatic renal injuries are uncommon. Our study demonstrates that even severe injuries can be safely managed without nephrectomy or embolization in the pediatric population. Urology consultation is beneficial but, given the low rate of intervention, can likely be reserved for the most complex injuries and those involving the collecting system. Given the wide range of injury severity and patient demographics seen in our study, these results should galvanize ongoing discussion around the use of angio-embolization in pediatric traumatic renal injury.
Table 1: Demographic Data
 N (%)95% Confidence Interval
Total29 (100) 
Average Age (years)12.95.0 - 20.7
Average SVI*0.340 - 0.88
Average ADI** (National %)32.10 - 66.71
Average SREI***-0.62-2.34 - 1.12
Race 
White23 (79.3) 
Black2 (6.9) 
Asian1 (3.4) 
Hispanic3 (10.3) 
Mechanism of Injury 
Penetrating Injury2 (6.9) 
Blunt Injury27 (93.1) 
Cause of Injury 
Sports9 (31.0) 
Skiing5 (17.2) 
MVC8 (27.6) 
Fall6 (20.7) 
Injured Kidney 
Right11 (37.9) 
Left15 (55.2) 
Both2 (6.9) 
Overnight Arrival22 (75.9) 
Transferred from Outside Facility9 (31.0) 

*SVI = Social Vulnerability Index, scored between 0 and 1
**ADI = Area Deprivation Index, presented as national percentile
***SREI = Structural Racism Effect Index, scored as standard deviations above or below the mean of 0


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