الفهرس 
ACKNOWLEDGEMENTOnly 14 pages are availabe for public view
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Abstract
Renal trauma in the pediatric population is predominately due to the blunt mechanism of injury. Children are more likely to sustain renal injury than adults following blunt abdominal trauma due to many predisposing anatomical factors. High-grade traumas have potentials of major risks related to the trauma, such as nephrectomy and patient’s death. Hence, preservation of the kidney functions and patient’s safety warrant a proper management plan. The latter should be implemented by effective initial physical examination, hemodynamic resuscitation, laboratory and radiological evaluation and grading. The current literature has a growing body of evidence that the conservative management can be safe and more effective than the surgical exploration for treatment of high-grade traumas. However, the literature is still lacking in consensus and guidelines for the definitions of the hemodynamic stability and the predictors of the successful management. There is need for additional studies to support the establishment of evidence-based recommendations.
The current prospective study was carried out to estimate the prevalence of different management modalities of renal trauma grades 3-5 in pediatrics and to evaluate the outcome of management of grades 3-5 renal trauma. This study was carried out at the Urology Department/Assiut University Urology Hospital and Trauma Unit, Assiut University Hospital, Assiut University. Patients were evaluated for hemodynamic stability and grading of renal trauma by physical, laboratory and imaging examinations. According to the hemodynamic stability, patients were allocated to receive conservative or surgical management.
The study included 43 patients with a mean age of 9.5 ± 4.6 years (Median =10 years and range= 2–18 years) and mean body mass index of 24.4 ± 5.3 kg/m2. They included 26 males and 17 females. At presentation, there were 28 patients with hemodynamic stability and 15 patients with instability.
In the comparison between both groups, the main findings were:
The demographic and clinical characteristics in the study groups were not significantly different, including hematuria.
The mean blood pressure values were significantly different between both groups and they improved significantly within each group individually with progress of management (p<0.001).
The hemoglobin values and serum creatinine levels showed non-significant differences between both groups.
Regarding the imaging variables, there were no significant differences between both groups.
There was non-significant difference between the studied groups as regard blood transfusion and length of hospital stay. However, patients who received conservative treatment had significantly longer length of hospital stay.
The conservative management was applicable to 37 (86%) patients, including 28 (100%) patients in the group of hemodynamic stability and 9 (60%) patients in the group of hemodynamic instability. It was successful in 32 (74.4%) patients, including 22 (78.6%) patients in the first group and 9 (60%) patients in the second group. Surgical interventions were used in 11 (25.6%) patients only.
The systolic blood pressure level at presentation was the only independent predictor of achieving a rigorous hemodynamic stabilization after hemodynamic resuscitations.
The indications of surgical intervention were the exploration by trauma general surgeons, hemorrhage and urine extravasation.
Nephrectomy was performed in 6 patients, representing a rate of 14% of total patients of the study and 55% of those needed surgical interventions.
There were no mortalities due to renal trauma in the current study, providing a rate of 0% in the current series.
In conclusion, the hemodynamic status at presentation was the key predictor of allocation of patients to receive conservative rather than interventional treatments. The initial hemodynamic stabilization increased the chances of providing a conservative management, which was effective in the treatment of patients with grades 3–5 renal trauma in pediatrics. However, the interventional managements were not associated with a significantly higher rate of blood transfusions, but it warranted a significantly shorter hospital stay. Only the SBP was identified as an independent predictor for the first day hemodynamic stabilization in multivariate regression analysis. This initial hemodynamic stabilization provided two main privileges in the management of pediatric renal trauma. Firstly, it helped allocate the patients to conservative management which was successful in about 75% of patients. Secondly, it contributed to preservation of the renal mass by reducing the rate of nephrectomy to less than 14% in this cohort of patients with high-grade renal trauma. No mortality happened in this cohort patients.
Based on the current results and the reviewed literature we recommend the following:
1- A consensus about the definition of the hemodynamic stability in pediatric renal trauma should be established: A standardized definition of the hemodynamic stability in pediatric renal traumas warrants conduction of larger sample studies and longer follow-up duration.
2- Predictors of rigorous response to hemodynamic resuscitation should be identified: The evidence-based identification of the risk factors of achieving a solid initial hemodynamic stabilization may warrant further prospective comparative studies.
3- Further predictors of renal function preservation in pediatric renal trauma should be studied and incorporated in a comprehensive predictive model.