What is the management of a grade V devascularized kidney?

Management of Grade V Devascularized Kidney

The presence of non-viable tissue (devascularized kidney) is not an indication for operative management in the acute setting in the absence of other indications for laparotomy. 1

Initial Assessment and Management

• Hemodynamic status is the primary determinant of initial management approach:

  • Hemodynamically unstable patients with no or transient response to resuscitation require immediate intervention (surgery or angioembolization in selected situations) 1
  • Hemodynamically stable patients with devascularized kidney can be managed non-operatively 1

• Diagnostic imaging with IV contrast-enhanced CT with immediate and delayed images should be performed when renal injury is suspected to accurately grade the injury and identify associated injuries 1

Management Algorithm for Grade V Devascularized Kidney

For Hemodynamically Unstable Patients:

• Immediate surgical intervention is indicated for:

  • Uncontrollable life-threatening hemorrhage 1
  • Avulsion of the renal pedicle with pulsating/expanding retroperitoneal hematoma 1
  • Renal vein lesion without self-limiting hemorrhage 1, 2

• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be used as a bridge to definitive hemorrhage control in severely unstable patients 1

For Hemodynamically Stable Patients:

• Non-operative management is the standard of care 1
• Follow-up CT imaging should be performed for all grade V injuries to monitor for complications 1
• Specific interventions based on complications:

For Vascular Complications:

• Angiography with super-selective angioembolization is indicated for:

  • Arterial contrast extravasation 1
  • Pseudoaneurysms or arteriovenous fistulas 1
  • Non-self-limiting gross hematuria 1

• For main renal artery injury in specialized centers:

  • Angioembolization or percutaneous revascularization with stent/stentgraft may be considered if warm ischemia time is <240 minutes 1
  • Success rates for arterial repair are only 25-35%, making this a challenging intervention 1

• For main renal vein injury without self-limiting bleeding:

  • Angioembolization is not indicated 1
  • Surgical intervention is required 1, 2

For Urinary Extravasation:

• Initial observation is appropriate for stable patients 1
• Urinary drainage should be performed if complications develop (enlarging urinoma, fever, increasing pain, ileus, fistula, infection) 1
• Drainage options include ureteral stent, possibly augmented by percutaneous urinoma drain or percutaneous nephrostomy 1

Long-term Considerations and Follow-up

• Functional outcomes for grade V devascularized kidneys are poor, with mean relative renal function of only 11% at 6 months post-injury 3

• Monitor for development of renovascular hypertension:

  • Some cases of renal injury result in significant renin-angiotensin-aldosterone cascade activation 1
  • Patients may develop persistent hypertension not responsive to anti-hypertensives 1
  • Periodic blood pressure monitoring for up to a year is recommended 1
  • In rare instances with uncontrollable hypertension and a functional contralateral kidney, delayed nephrectomy may be necessary 1, 4

• Long-term follow-up is warranted for all grade IV and V injuries due to meaningful risk of adverse outcomes 5

Special Considerations

• Nephrectomy rates for grade V injuries remain high (90.9%) when surgical exploration is required, particularly with hemodynamic instability 6
• Patients with blunt trauma causing grade V injuries have worse outcomes compared to those with penetrating injuries (odds ratio 2.29) 4
• Attempted arterial repair is associated with poor outcomes compared to immediate nephrectomy in patients with grade V injuries and a functioning contralateral kidney 4

Common Pitfalls to Avoid

• Rushing to surgery for a devascularized kidney in a hemodynamically stable patient without other indications for laparotomy 1
• Attempting arterial repair in a severely damaged kidney with prolonged warm ischemia time (>240 minutes) 1
• Failing to perform follow-up imaging for grade V injuries, which have high complication rates 1
• Not monitoring for renovascular hypertension, which can develop as a late complication 1