What is the treatment for a devascularized kidney?

Management of a Devascularized Kidney

For a devascularized kidney (Grade V renal injury), the treatment approach depends primarily on the patient's hemodynamic status, with immediate surgical intervention indicated for hemodynamically unstable patients and non-operative management preferred for stable patients. 1

Initial Assessment and Management

• Hemodynamic status is the primary determinant for management approach - unstable patients require immediate intervention while stable patients can be managed non-operatively 2, 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 1
• Renal venous pedicle avulsion is the only absolute contraindication for non-operative management (NOM) and angioembolization (AE), requiring immediate surgery 2

Management Algorithm Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Immediate surgical intervention is indicated for:
  • Uncontrollable life-threatening hemorrhage
  • Avulsion of the renal pedicle with pulsating/expanding retroperitoneal hematoma
  • 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
• Nephrectomy is often necessary in these cases, as attempts at revascularization have poor outcomes 2

Hemodynamically Stable Patients

• Non-operative management is the standard of care for hemodynamically stable patients 1, 2
• Angiography with super-selective angioembolization is indicated for:
  • Arterial contrast extravasation
  • Pseudoaneurysms or arteriovenous fistulas
  • Non-self-limiting gross hematuria 1, 2
• 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

Revascularization Options and Outcomes

• Results of kidney artery surgical revascularization are poor, with long-term kidney function preservation rate of less than 25% 2
• Percutaneous revascularization with stents has shown better outcomes on renal function than surgical treatment 2
• Warm ischemia time longer than 60 minutes leads to significant exponential losses in kidney function 2
• The management of renal pedicle avulsion is debated, with some reporting angioembolization success rates of 80% (requiring repeat procedures) while others report 100% failure rates 2

Special Considerations

• In cases of shattered kidney without renal hilum avulsion, angioembolization can be effective 2
• For renal artery occlusion, conservative management often leads to severe hypertension requiring subsequent nephrectomy 2
• In specialized centers with appropriate expertise, peripheral stent graft placement may be considered for hemostasis while allowing perfusion of the renal artery distal to the injury site 2
• Selective balloon occlusion can be used as a temporary bleeding control measure prior to laparotomy, causing less global ischemia compared to aortic balloon occlusion 2

Long-term Monitoring and Follow-up

• Monitor for development of renovascular hypertension with periodic blood pressure monitoring for up to a year 1
• Follow-up CT imaging should be performed to monitor for complications 1
• In rare instances with uncontrollable hypertension and a functional contralateral kidney, delayed nephrectomy may be necessary 1

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