Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.     

Laparoscopic diagnosis of blunt abdominal trauma in children

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10–60 min under an insufflation pressure of 10–12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.     

儿童重度闭合性肾挫裂伤的处理

目的 探讨儿童重度闭合性肾挫裂伤的处理.方法 回顾性总结分析2000至2008年临床诊治小儿闭合性肾损伤33例,重点是其中的15例重度肾挫裂伤(3例系肾积水合并肾挫裂伤的特殊病例)的资料.结果 全组无死亡,无早期肾切除病例,18例轻度肾损伤经保守治疗愈合.15例重度闭合性肾挫裂伤患儿中,其中8例采用保守治疗成功,1例肾蒂血管损伤早期急诊行肾静脉修补术,3例行选择性肾动脉栓塞治疗,3例肾积水外伤后肾破裂.3例肾积水肾破裂中,2例行早期肾盂成形肾周引流术,1例因合并肾功能不全,对侧肾萎缩,早期作肾造瘘,延期肾盂成形术,重度肾损伤病例随访5～28个月(平均18个月).4例继发尿性囊肿,1例早期行肾盂输尿管吻合,3例延期做尿性囊肿剥离切除;1例6个月后出现高血压、受损肾萎缩行肾切除.结论 轻度的肾损伤采用保守治疗易于治愈,重度的肾损伤因应病情选用相宜的方法 处理,绝大多数不需早期手术探查,以减少肾切除,选择性肾动脉栓塞微创止血效果好,重度肾挫裂伤需要密切随访,以处理相续可能发生的尿性囊肿和高血压等并发症.     

Total severance of renal pedicle caused by blunt trauma in children

In two children complete severance of the renal vascular pedicle was the consequence of falling from a considerable height. Pre-operative diagnosis was established by retrograde aortography. In both these children there were additional injuries; one child had a splenic injury, the other a liver injury. One child survived but the other died. The importance of utilising retrograde aortography to define the nature of the injury is discussed in the context of a critical clinical situation necessitating emergency surgery.     

Isolated rupture of an accessory liver from blunt abdominal trauma in childhood

 An accessory liver is uncommonly encountered in surgical practice. It can rarely cause acute abdominal pain. An isolated injury to an accessory liver from blunt trauma in a 10-year-old boy caused major intraperitoneal haemorrhage. Laparotomy and excision of the lacerated accessory liver lobe was necessary; the patient recovered uneventfully. The literature on accessory liver is reviewed. Accepted: 18 December 2000     

The utility of initial and follow-up ultrasound reevaluation for blunt renal trauma in children and adolescents

ObjectiveTo discover if renal ultrasound (RUS) can be utilized as the primary follow-up imaging modality in the management of blunt renal injuries in children and adolescents.MethodsWe initiated a protocol utilizing RUS reevaluations for children and adolescents treated for blunt renal injuries. Patients following this protocol (Post) had initial computerized tomography (CT) with RUS reevaluation at day 2 and 2 weeks. We retrospectively compared this group to a 2-year cohort treated between 2007 and 2009 (Pre).ResultsIn our study, 28 Post protocol patients were retrospectively compared with 22 Pre cohort patients. No significant differences were observed in age, length of stay (LOS), injury severity score (ISS), and utilization of CT reevaluation. Follow-up reevaluation was obtained in 13 Pre patients versus 21 Post patients (p = 0.231). No patients had any evidence of long-term complications in either cohort.ConclusionOur results suggest that RUS can be utilized as the primary surveillance imaging modality in the management of blunt renal injuries in children and adolescents. The lack of benefit of usage of RUS demonstrated in the acute post-injury surveillance period calls into question the benefit of RUS immediately following the blunt trauma.     

小儿闭合性肾损伤的治疗(附75例分析)

目的探讨小儿闭合性肾损伤的最佳治疗方案。方法回顾性分析75例小儿闭合性肾损伤临床资料。其中肾被膜下血肿29例,肾实质部分裂伤23例,肾实质完全断裂11例,肾实质碎裂7例,肾蒂伤2例,肾盂输尿管连接处断裂3例。合并其他脏器伤者16例。结果非手术治疗59例,手术治疗16例,切除伤肾11只。74例治愈,死亡1例。结论小儿肾损伤后应尽快判断出肾脏损伤的程度及出血情况,根据病情选择不同的治疗方案;绝大多数闭合性肾损伤可采用非手术治疗。     

Rupture of the right hemidiaphragm due to blunt trauma in children: a diagnostic dilemma

 The diagnosis of right-sided diaphragmatic rupture (RDR) due to blunt abdominal trauma is often missed in the acute setting, especially in the absence of other thoracoabdominal injuries. We describe two such children. The problems associated with the diagnosis and management of RDR are discussed to emphasize the need to have a high index of suspicion for this entity.     

胱抑素C诊断危重病儿童肾损害的临床价值

目的 了解血清胱抑素C(CysC)在危重病儿童肾损害诊断中的临床价值.方法 对2007年1月至2008年12月在我院PICU住院的142例危重病患儿测得的CysC、血清肌酐(SCr)和内生肌酐清除率(Ccr)数据进行归纳整理,疾病危重程度依据小儿危重病例评分法评分.以CysC＞1.50 mg/L为阳性,根据传统金标准Ccr＜80ml/(min·1.73m~2)诊断为肾损害,对肾损害进行受试者工作特征(ROC)曲线分析,获得最佳诊断界点值,评价其敏感性和特异性.结果 根据Ccr标准和CysC标准得出的肾损害诊断率分别为40.8%(58/142)、50.7%(72/142),差异有非常显著性(χ~2=64.93,P＜0.001);ROC曲线分析显示肾损害最佳诊断界点为1.55 mg/L,敏感性94.8%,特异性81.0%.ROC曲线下面积为0.98(95%CI 0.97～0.98),用于诊断危重病儿童.肾损害有统计学意义(P=0.000).结论 CysC标准诊断危重病儿童肾损害有临床意义,与Ccr标准相比,能够提高肾损害诊断敏感性和特异性.     

Microfocal radiography in the diagnosis of childhood renal osteodystrophy

Abstract Background: Renal osteodystrophy is common in children with chronic renal failure (CRF) and X-ray is an intensive method in the diagnosis of the disease. In this study we compared microfocal radiography with conventional method for the diagnosis of renal osteodystrophy.
Methods : The X-rays of left wrists of 21 children with CRF and chronic renal insufficiency were taken by conventional and microfocal methods.
Results : Both methods revealed osteopenia in all patients (100%), widening, fraying and cupping of ulnar and radial metaphysis in 10 (47.6%), osteosclerosis in three (14.2%) and pseudofracture in one (4.7%) patient. Microfocal radiography demonstrated osteosclerosis in one patient, pseudofracture in four and subperiosteal resorption in five patients that were not detected by conventional method.
Conclusion : Two methods were found to be significantly different in demonstrating the changes due to rickets and hyperparathyroidism and it is concluded that microfocal radiography may be preferred in the diagnosis of childhood renal osteodystrophy.     

Nonoperative management of intra-abdominal bleeding due to blunt trauma in children: the risk of missed associated intestinal injuries

Nonoperative management of intra-abdominal bleeding (IAB) from blunt injuries in children has been advocated for many years. Nonoperatively managed patients, however, are at risk for missed associated intestinal injuries. To evaluate this question, we reviewed the charts of 120 children who had traumatic IAB; 106 were initially managed nonoperatively and observation failed in 2. Fourteen underwent emergency operation. Forty patients had isolated liver and/or splenic injuries while the others had injuries associated with several organs. During observation peritonitis developed in 3 patients and further radiologic examinations failed to confirm an intestinal injury. Diagnostic peritoneal lavage demonstrated contaminated blood and fecal particles from injured intestines in 3 patients; they underwent emergency operation at 10, and 26 h after admission. There was no mortality or morbidity associated with delayed treatment. These data suggest that the majority of patients with IAB may be successfully treated nonoperatively, but associated intestinal injuries should be suspected in all cases. Accepted: 16 May 1997     

缺氧缺血性脑病新生儿尿大分子碱性磷酸酶的研究

目的研究缺氧缺血性脑病（HIE）新生儿尿大分子碱性磷酸酶（HMAP）水平的变化及其早期诊断肾功能损害的价值。方法HIE组包括轻度脑病52例和中重度脑病40例。利用抗HMAP的单克隆抗体，用免疫催化方法检测92例HIE患儿治疗前后及30例正常新生儿（对照组）尿HMAP水平，并测定两组尿＆．微球蛋白（β2-MG）水平。结果HIE组治疗前尿HMAP、β2-MG水平高于治疗后（t=28．15、t=16．12，P〈0．01）和对照组（t=11．89、t=12．34，P〈0．01），且中重度HIE组尿HMAP高于轻度组（t：2．35，P〈0．05）；HIE组尿HMAP的异常发生率（85．9％）显著高于β2-MG（65．2％）（Y2=10．62，P〈0．01）；HIE组尿HMAP与β2-MG呈直线正相关（r=0．56，P〈0．01）。结论HIE新生儿大多存在肾功能损害，尿HMAP比＆．MG更灵敏地反映HIE时肾损害的程度，可早期发现HIE新生儿肾损害。     

Pitfalls in the differential diagnosis of renal tumor in an adolescent

The differential diagnosis of renal tumors, particularly in adolescents, may be challenging. We describe an 11‐year‐old female with a primary intra‐renal mass. Initial differential diagnoses included primitive neuroectodermal tumor (PNET), desmoplastic small round cell tumor (DSRCT), and Wilms Tumor (WT). Extensive pathologic and molecular analysis on initial and relapsed tumor samples confirmed WT. The EWS‐WT1 and EWS‐FLI1 rearrangements, distinctive of DSRCT and PNET were negative. The differential diagnosis on monophasic blastemal WT may be complex. Primary renal DSRCT and PNET have been rarely described. Nevertheless, molecular confirmation for these rare conditions may be necessary in selected cases. Pediatr Blood Cancer 2010;54:319–321. © 2009 Wiley‐Liss, Inc.     

Mortality in pediatric renal transplantation: A study of the French pediatric kidney database

Abstract: Objective and Methods: To assess patient survival in pediatric renal transplantation, we retrospectively reviewed 573 transplants in 553 patients, registered from 1995 to 2005. Results: Mean age at transplantation was 9.9 years. Patient survival at 1, 5 and 10 years was respectively 99%, 97% and 96%. Death occurred at a median time of 2.6 years after transplantation. Long‐term patient survival was significantly lower in recipients younger than 5 years old. Seventeen patients (3.1%) died. Two deaths occurred while under maintenance dialysis. Among the remaining patients, the two main causes of death were infections (33%) and malignancies (27%). Interestingly, initial disease‐related complications were a major cause of death (34%). Conclusion: A low mortality rate was observed, with the majority of deaths due to malignancies and infections, and with a notable participation of complications related to the initial disease. No impact of cardiovascular disease was noted with the given follow‐up period. Improvements in managing immunosuppression may contribute to reducing mortality in pediatric renal transplantation.     

Radioisotopic evaluation of the renal parenchymal function in children with ureteropelvic junction obstruction. A retrospective study

Separate glomerular filtration rates were evaluated in 21 children with uni- or bilateral ureteropelvic junction stenosis, using the Tc-99m DTPA complex and the scintillation camera.The grade of alteration seen on urograms has influenced the surgeon in his decision to use a conservative or a surgical treatment, whereas the type of intervention (pyeloplasty or nephrectomy) was mainly based on the scintigraphic quantitation. The morphological data provided by an excretory urogram could not predict the degree of functional impairment.The scintigraphic evaluation of single kidney clearance was useful in the evaluation of the effects of medical and surgical treatment.Abbreviations PUJ Pelvi-ureteric junction obstruction - SGFR separate glomerular filtration rate - GFR glomerular filtration rate Offprint requests to: St Peter's Hospital, Dept. of Radioisotopes, Rue Haute 322, B-1000 Brussels, Belgium