Delayed Management of High-Grade Renal Trauma in a Child with Bilateral Lower Polar Artery: A Case Report

High-grade renal trauma rarely occurs due to low-velocity mechanisms. With its clinical presentation, delayed diagnosis rarely happens. We report the case of a 12-year-old girl diagnosed seven days post-trauma with grade IV renal trauma complicated with infected urinoma and bilateral lower polar vessels. She was non-operatively managed with ultrasound-guided percutaneous drainage of the urinoma, which resolved, and had unremarkable six months follow-up. We discuss the role of preexistent hydronephrosis in low-velocity impact, pitfalls of diagnosis in resource-constrained settings, and management of high-grade trauma.

Imaging in renal trauma

Renal injuries are classified,based on the American Association for the Surgery of Trauma classification,in to five grades of injury.Several imaging modalities have been available for assessing the grade of renal injury,each with their usefulness and limitations.Currently,plain radiographs and intravenous urography have no role in the evaluation of patients with suspected renal injury.Ultrasonography(USG) has a limited role in evaluating patients with suspected retroperitoneal injury;however,it plays an important role during follow up in patients with urinoma formation.USG helps to monitor the size of a urinoma and also for the drainage procedure.The role of selective renal arteriography is mainly limited to an interventional purpose rather than for diagnostic utility.Retrograde pyelography is useful in assessing ureteral and renal pelvis integrity in suspected ureteropelvic junction injury and for an interventional purpose,like placing a stent across the site of ureteric injury.Magnetic resonance imaging has no role in acute renal injuries.Multidetector computed tomography is the modality of choice in the evaluation of renal injuries.It is also useful in evaluating traumatic injuries to kidneys with preexisting abnormalities and can help to define the extent of penetrating injuries in patients with stab wounds in the flank region.The combination of imaging findings along with clinical information is important in the management of the individual patient.This article will describe a spectrum of renal injuries encountered in a trauma setting.

Emergency department management of an occult renal laceration following a minor fall

We present a case of a pediatric patient with high grade renal injury following a minor fall,where clinical suspicion of occult injury resulted in diagnosis.Additionally,we review the management of high grade renal lacerations in children,including the role of ultrasound in managing these injuries.

Autologous omentum transposition for regeneration of a renal injury model in rats

Background:After renal trauma,surgical treatment is vital,but sometimes there may be loss of function due to fibrosis.This study aimed to evaluate the effect of autologous omentum flaps on injured renal tissues in a rat model.Methods:A total of 30 Wistar albino rats were included and randomly divided equally into a control group and four intervention groups.Iatrogenic renal injuries were repaired using a surgical technique(primary repair 1 group and primary repair 2 group)or transposition of the autologous omentum(omentum repair 1 group and omentum repair 2 group).Blood samples were taken preoperatively and on the 1st and 7th postoperative days in all groups and on the 18th postoperative day in the control and two intervention groups.All rats were sacrificed on the 7th or 18th day postoperatively,and their right kidneys were taken for histopathological evaluation.Results:The mean urea level significantly decreased from day 1 to day 7 and from day 1 to day 18 in the omentum repair 2 group(P=0.005 and P=0.004,respectively).There were no other significant changes in urea or creatinine levels within the intervention groups(P>0.05).There was no significant correlation between the urea and creatinine levels and the histological scores(P>0.05).The primary repair 1 and 2 groups had significantly higher median granulation and inflammation scores in the kidney specimen than the control and omentum repair groups(P<0.05).The omentum repair 2 group had significantly lower median granulation and inflammation scores in the surrounding tissues than the primary repair 2 group(P<0.05).The completion score for the healing process in the kidney specimen was significantly higher in the omentum repair groups than in the primary repair groups(P<0.05).The omentum repair 2 group had significantly lower median granulation and inflammation scores in the surrounding tissues than the primary repair 2 group(P<0.05).Granulation degree in the kidney specimen was strongly and positively correlated with the inflammation degree(r=0.824,P<0.001)and foreign body reaction in the kidney specimen(r=0.872,P<0.001)and a strong and negative correlation with the healing process completion score in the kidney(r=−0.627,P=0.001).Inflammation degree in the kidney specimen was strongly and positively correlated with the foreign body reaction in the kidney specimen(r=0.731,P=0.001)and strongly and negatively correlated with the healing process completion score in the kidney specimen(r=−0.608,P=0.002).Conclusion:Autologous omentum tissue for kidney injury repair attenuated inflammation and granulation.Additionally,the use of omental tissue to facilitate healing of kidney injury may theoretically lead to a more effective healing process and reduced fibrosis and tissue and function loss.

Predictors of renal angioembolization outcome:A retrospective analysis with 148 patients at a tertiary urology institute

Objective:The aim of this study was to evaluate the predictor of unsuccessful outcome of renal angioembolization(RAE).Knowing those predictors may help in avoiding unnecessary RAE procedures and their associated side effects,while helping to prepare for an alternate procedure and improving patient's overall satisfaction.Methods:A retrospective analysis between January 2006 and December 2018 was performed,and the indications for RAE were classified into post-traumatic,iatrogenic,renal tumors,and spontaneous.Patients who underwent RAE prior to nephrectomy were eliminated.Computed tomography angiography was performed in patients with normal renal function and those who had no contrast allergy,otherwise magnetic resonance angiography was performed.For the purpose of statistical analysis,we stratified patients into two main categories based on the final outcome—successful or failed.Results:Of 180 patients,32 with negative angiography were eliminated,leaving 148 patients;136(91%)had successful outcomes after one or more trials and 12 had unsuccessful outcomes.The mean age was 45±15 years,and 105(71%)were male.Neither gender,side of the lesion,presence of hematuria,indication for RAE,nor the type of lesion affected the outcome.On the other hand,renal anatomy with presence of accessory artery was the only predictor to failed RAE(p=0.001).Failed RAE trial was a predictor for nephrectomy as a secondary procedure(p=0.03).Conclusion:No pre-procedural predictors could anticipate the RAE outcome,and different indications can be scheduled to RAE,which is equally effective.The presence of accessory renal artery on diagnostic angiography is the only factor that may predict the failure of the procedure.

微血流成像联合超声造影诊断猪肾创伤伴活动性出血的实验研究

目的探讨微血流成像(MFI)联合超声造影(CEUS)在猪肾创伤伴活动性出血诊断及定位中的应用价值。方法选取健康巴马小型猪10只,建立肾创伤伴活动性出血模型。模型建立成功后进行CEUS及MFI检查,比较MFI联合CEUS与CEUS诊断及定位活动性出血的准确率;应用MFI联合CEUS测量活动性出血受损血管破口内径。结果1只巴马小型猪由于麻醉原因在实验过程中意外死亡,剩余9只巴马小型猪共成功构建18处肾创伤伴活动性出血灶。CEUS与MFI联合CEUS诊断活动性出血的准确率分别为77.78%、94.44%,二者比较差异无统计学意义;CEUS与MFI联合CEUS定位活动性出血的准确率分别为55.56%、94.44%,二者比较差异有统计学意义(P<0.05)。MFI联合CEUS测得活动性出血受损血管破口内径为1.54~2.42 mm,平均(1.94±0.29)mm。结论MFI联合CEUS能清晰显示猪肾创伤灶内受损血管,准确诊断活动性出血,且定位活动性出血的能力优于CEUS。

高密度脂蛋白胆固醇对严重创伤患者急性肾损伤的预测效果

目的分析高密度脂蛋白胆固醇(HDL-C)对严重创伤患者急性肾损伤(AKI)的预测效果。方法选取2018年6月至2021年6月西安航天总医院收治的84例严重创伤患者作为研究对象,根据是否继发AKI分为AKI组(12例)和对照组(72例),对两组患者各项一般资料和临床资料进行比较,对差异有统计学意义的指标/因素进一步进行多因素Logistic回归分析,明确严重创伤患者继发AKI的危险因素,并采用Pearson相关分析HDL-C水平与各项危险因素的相关性,以受试者工作特征曲线分析各项危险因素单独及联合检测预测严重创伤患者继发AKI的价值。结果与对照组比较,AKI组年龄、心率、创伤严重程度(ISS)评分、急性生理与慢性健康状况评分、3项并发症及5项非肾脏器官功能障碍发生率、血管活性药物使用率、丙氨酸氨基转移酶、天门冬氨酸氨基转移酶、总胆红素、低密度脂蛋白胆固醇水平均升高,格拉斯哥昏迷评分、血尿酸、血红蛋白、血小板计数、HDL-C水平均降低,差异均有统计学意义(P<0.05)。ISS评分>16分、HDL-C<1.04 mmol/L为严重创伤患者继发AKI的危险因素(P<0.05)。严重创伤患者HDL-C水平与ISS评分呈负相关(P<0.05)。ISS评分、HDL-C水平对严重创伤患者继发AKI均有一定的预测价值,且2项指标联合检测的预测效果优于各项指标单独检测。结论HDL-C水平降低为严重创伤患者继发AKI的危险因素,并且与ISS评分呈负相关,对严重创伤患者继发AKI有一定的预测价值。

连续性肾脏替代治疗在严重多发战创伤救治卫勤保障中的应用展望

随着科技的发展,现代武器的种类变多,未来战争作战的伤类伤情将愈发复杂,多发伤将是未来战争的常见伤情,这将大大增加战伤救治的难度。随着急诊重症医学的发展,连续性肾脏替代治疗(continuous renal replacement therapy, CRRT)已在各类多发伤急危重症的救治中得到广泛应用。本文分析了CRRT技术应用于野战医疗队及后方医院严重多发伤患者救治卫勤保障中的前景,以及可能存在的问题,并给出了相应对策,旨在提高我军面对未来战争时的卫勤保障能力。

肾损伤的CT诊断及临床治疗相关性研究

目的 :研究复合性肾损伤的CT表现 ,探讨其对临床治疗的指导意义。方法 :对 5 8例肾损伤的CT资料及临床处理进行回顾性分析。结果 :5 8例肾损伤中有肾挫伤 10例 ,单纯肾包膜下血肿 13例 ,肾挫裂伤 14例 ,肾撕裂伤 15例 ,肾粉碎伤 2例 ,肾蒂伤 4例。发现伤前肾脏疾病 6例 ,肾外合并伤有肝脾破裂、肺挫伤、血气胸、多个部位骨折等。手术切除患肾 5例 ,17例行肾动脉栓塞治疗。结论 :CT对肾损伤的诊断迅速有效 ,对于损伤的分类 ,有无严重合并伤 。

创伤性肾出血的DSA诊断与介入栓塞治疗

目的评价创伤性肾出血的DSA诊断与介入栓塞止血治疗的临床应用价值。资料与方法48例创伤性肾出血患者均行肾动脉DSA检查,栓塞材料采用明胶海绵、聚乙烯醇(PVA)微粒或弹簧钢圈。结果48例肾内血管损伤患者经选择性或超选择性肾动脉造影均获得了明确的诊断,36例可见对比剂外溢;7例肾内受损动脉痉挛、移位,末梢血管不规则、毛糙、其中3例合并动-静脉瘘;5例肾内受损动脉分支中断、缺支,其中2例合并假性动脉瘤。6例单纯采用明胶海绵栓塞后,其中2例分别于术后7天、12天再发血尿,其余病例采用PVA微粒或弹簧钢圈栓塞均一次成功。所有患者肉眼血尿术后平均3天消失,平均随访18个月无肾出血复发,血尿素氮、肌酐及血压正常,静脉尿路造影见肾未栓塞部分肾功能正常,栓塞部分肾盏有不同程度变形。结论DSA是诊断创伤性肾出血的可靠方法,选择性肾动脉栓塞治疗创伤性肾出血微创、疗效好且迅速、并发症少,能最大程度保护损肾功能。选择恰当的栓塞材料可以减少复发率及异位栓塞。

携带凝血酶原复合物的阴离子脂膜微泡造影剂联合超声治疗对兔肾创伤性出血模型的止血效果

目的探讨携带凝血酶原复合物的阴离子脂膜微泡(PCCMB)造影剂联合超声治疗对兔肾创伤性出血模型的止血效果。方法对24只健康新西兰大白兔建立兔肾创伤性出血模型,并随机分为3组,即单纯超声治疗组(US组)、单纯PCCMB注射组(SHAM组)及PCCMB注射联合超声治疗组(PCCMB+US组),每组各8只。对各组均通过10min出血量及视觉评分评价止血效果。并对SHAM组及PCCMB+US组于超声治疗前和治疗后即刻、治疗后60min行CEUS检查,对US组于超声治疗后即刻及治疗后60min行CEUS检查,测量兔肾造影峰值强度(PI)。结果所有实验兔均顺利完成实验。治疗后PCCMB+US组10min出血量低于SHAM组及US组(P均<0.05);PCCMB+US组视觉评分明显低于SHAM组及US组(P均<0.05)。PCCMB+US组超声治疗后即刻及治疗后60min的PI均高于超声治疗前(P均<0.05)。SHAM组及US组超声治疗前与治疗后即刻及治疗后60min PI差异均无统计学意义(P均>0.05)。结论PCCMB造影剂联合超声治疗对兔肾脏创伤性出血可起到快速、有效止血的效果。

选择性肾动脉栓塞治疗损伤性肾出血

目的 观察选择性肾动脉栓塞治疗急性损伤性肾出血的疗效。方法 回顾性分析2008年6月—2011年12月32例损伤性肾出血行选择性肾动脉栓塞治疗情况，其中包括肾挫裂伤18例，肾部分切除术术后出血2例，经皮肾镜术后出血12例。结果 31例患者一次栓塞成功，1例患者栓塞术后第5天再次出血行第2次栓塞术后血尿消失。术后随访2 ～ 40个月，未见肾出血再发，1例出现肾周尿液囊肿；2例肾脏体积缩小，该2例均为Ⅴ级肾挫裂伤患者。随访期间无肾脓肿、肾性高血压及肾功能异常发生。结论 选择性肾动脉栓塞是治疗急性损伤性肾出血微创、有效、安全的治疗方法。

肾脏损伤早期肿瘤坏死因子-α表达的实验研究

目的探讨外源性肾上腺髓质素（ADM）对肾脏机械性损伤早期肿瘤坏死因子-α（TNF-α）表达的影响。方法选健康成年普通级Wistar大鼠104只,随机分为4组：对照组8只、创伤组32只、伤前给药组32只、伤后给药组32只,后3组的动物分别于创伤后1、6、12、24h各处死8只。采用自由落体打击仪直接打击大鼠脊肋区制作肾脏机械性损伤模型。ADM分别于创伤前或创伤后10min采用腹部注射法给药。实验动物采用快速心脏采血法处死。迅速解剖动物提取下肾脏标本,10%甲醛固定,免疫组化染色观察TNF-α在组织中的表达规律。结果创伤组于创伤早期TNF-α表达均高于对照组,外源性ADM早期（1、6h）可抑制TNF-α表达（P〈0.05）。结论 TNF-α在创伤早期即参与了肾组织炎症的急性期反应并加重损伤。ADM能降低巨噬细胞的白细胞趋化物的分泌水平,降低TNF-α的分泌。

肾损伤450例的诊断和治疗

目的 提高肾损伤的诊疗水平。方法 对450例肾损伤进行了回顾性分析。结果 闭合性损伤423例,开放性损伤27例, 合并伤227例。B超阳性率68.2%,双倍剂量IVU阳性率47.9%,CT阳性率100%。根据病情分别选择手术与保守治疗,非手 术治愈365例,超选择性肾动脉栓塞4例,手术治愈67例,死亡14例。结论 B超检查快捷安全,应作为肾损伤首选检查方法, 在诊断中主要起到筛选作用。CT扫描为肾损伤程度分类和选择治疗方案提供可靠依据,应作为重度肾损伤和术前常规检查方 法。治疗取决于伤情,保守治疗是重要的治疗方法,严格掌握手术和非手术治疗指征是处理肾损伤的关键。

肾损伤伴严重尿外渗的临床处理及随访

目的总结我科5年来收治的肾损伤合并严重尿外渗的处理及转归。方法对21例肾外伤伴严重尿外渗患者，通过静脉尿路造影、CT、彩超等检查确诊后，18例入院后安放伤侧输尿管支架管引流尿液并进行随访行保守治疗，3例由于血流动力学不稳定行急诊手术探查。结果21例肾外伤伴尿外渗患者17例（Ⅳ级损伤）保守治疗成功，随访5～46个月，肾功能均正常，无血尿、结石、肾性高血压等并发症的发生；3例急诊开放行肾切除术，1例Ⅱ期行部分肾切除术，所有需外科处理的患者均为高级别肾损伤Ⅳ或Ⅴ级。结论肾损伤伴严重尿外渗患者（Ⅳ级损伤）早期安放输尿管内支架经保守治疗多数可获良好疗效。

闭合性肾损伤的诊断与治疗(附132例报告)

目的 :总结闭合性肾损伤的诊断与治疗。方法 :对 1 32例闭合性肾损伤的临床资料进行回顾性分析。结果 :1 32例闭合性肾损伤中 ,肾挫伤 96例 ,肾裂伤 2 1例 ,肾粉碎伤 1 5例 ,并发伤 36例。血尿、腰部疼痛是主要的临床症状。保守治疗 87例 ,超选择性肾动脉栓塞术 6例 ,手术治疗 39例。死亡 6例。结论 :B超和CT检查是诊断肾损伤的有效方法。迅速而准确的伤情评估 ,严格掌握手术时机是治疗闭合性肾损伤的关键。

肾损伤输尿管喷尿的彩色多普勒超声表现及临床意义

目的：应用彩色多普勒超声以观测血流的方法，通过对输尿管膀胱开口处喷尿情况的观测，探讨肾损伤时输尿管喷尿的特征性表现及临床意义。方法：选择急性单侧闭合性肾损伤患者35例，于饮水500rrd后30-60min动态观测正常侧与肾损伤侧输尿管12的尿流形态、尿流速度、喷尿频率。结果：饮水30min后尿流速度与喷尿频率逐渐加快，于50min达最大峰值。正常侧彩色多普勒尿流呈鲜红色，尿流速度22—49cm／s，喷尿频率4—8次／min。损伤侧尿流射程明显变短，色彩暗淡，严重者可无彩色尿流显示，尿流速度0～18cm／s，喷尿频率0～3次／min。尿流速度与喷尿频率的降低程度随肾损伤加重而加重。结论：输尿管喷尿对肾泌尿功能的改变极为敏感，肾损伤时通过观测输尿管喷尿的峰值指标，可判定有无肾损伤及损伤的大致程度。

超选择性肾动脉栓塞术治疗严重肾创伤

目的:探讨超选择肾动脉栓塞术治疗严重外伤性肾损伤的临床价值。方法:12例经动脉造影证实的严重肾外伤出血患者,全部采用明胶海绵及金属圈行超选择性肾动脉栓塞术。结果:11例术后第1天内肉眼血尿完全消失,1例术后第2天肉眼血尿消失。12例1个月后静脉尿路造影显示患肾功能存在,1例部分肾盏显影不满意。结论:超选择性肾动脉栓塞术治疗严重性肾创伤疗效肯定,并发症少,是一种安全、有效的治疗方法。

选择性肾动脉栓塞术治疗肾损伤出血(附29例报告)

目的探讨肾损伤出血行超选择性肾动脉栓塞术的临床价值。方法 29例肾损伤性血尿患者行超选择性肾动脉栓塞治疗。栓塞材料选用明胶海绵粒、聚乙烯醇(PVA)和带纤毛弹簧圈。结果全部病例超选择栓塞治疗后疗效满意。带纤毛弹簧圈作为低压栓塞剂较明胶海绵和PVA粒定位准确,患肾更多保留了未栓塞部功能。结论对于肾损伤出血的患者可行超选择肾动脉栓塞术,此法疗效肯定、创伤小、并发症少、可避免肾切除术。栓塞材料的选择要根据肾损伤具体情况加以选择才能达到满意疗效。

闭合性肾损伤的临床分析

目的:总结闭合性肾损伤的诊治体会,提高肾损伤的诊治效果。方法:回顾性分析124例闭合性肾损伤患者的临床资料。结果:124例闭合性肾损伤中,保守治疗96例(77.4%),超选择性肾功脉栓塞治疗2例(1.6%),手术治疗26例(21%),其中14例同时施行了腹部合并伤手术。死亡2例,死亡率1.6%。结论:B超、CT是诊断肾损伤主要的、有效的方法,大剂量IVU亦是重要的措施。