Outcomes of Renal Trauma in Indian Urban Tertiary Healthcare Centres: A Multicentre Cohort Study

Injuries account for 10% of global mortality which translates to around 4.5 million annual deaths [1]. It is estimated that more than 1000 non-fatal injuries occur for every injury related death [2, 3]. Globally, renal trauma is present in approximately 0.5–5% of patients with traumatic injury and 10–20% of patients with abdominal trauma [4‐6].

The American Association for the Surgery of Trauma (AAST) classifies renal trauma into five grades of increasing severity [7]. Advances in imaging and endovascular techniques in high-income settings (HICs) have resulted in an increase in nonoperative management of renal trauma, including those with high AAST grades (III–V) [8‐10]. Nephrectomy in these settings is often reserved for patients with persistent shock or sepsis, or when endovascular techniques or intensive care facilities are limited [10, 11].

Several recent studies from India and other low- and middle-income countries (LMICs) have also described renal trauma management with a nonoperative approach but these are all single centre studies with small sample sizes [12‐14]. We used a large trauma cohort encompassing four public urban tertiary healthcare centres in India [15] to characterise patients with renal trauma and observe their management and outcomes.

Over the study period, 16,047 trauma patients were admitted and enrolled in the TITCO cohort. Abdominal trauma comprised 1119 (7%) cases, of which 144 (13%) had renal trauma. Renal trauma was present in 1% of patients admitted for trauma (Fig. 1).

The demographic and clinical profile of the patients with renal trauma listed is shown in Table 1. The mean age was 28 years (SD-14.7), age following a unimodal distribution, with young adults (20–40 years), being the most affected (Fig. 2). A total of 119 (83%) patients were male. Blunt trauma was the predominant mode of injury (93%). Road traffic injuries (RTIs) were the commonest mechanism (53%) followed by falls (29%). On sub-categorisation of patients with renal trauma due to RTIs, we observed that pedestrians and motorcyclists constituted around 47% (36/76) of patients having renal trauma. Grade V renal trauma was seen in motorcyclists and drivers. 76% of patients with renal trauma had no or mild traumatic brain injury (TBI) with GCS 13–15. 3% and 14% patients had moderate (GCS 9–12) and severe (GCS ≤ 8) TBI, respectively. The median ISS was 17 (IQR- 9–21). Patients with grade IV and V renal trauma had predominantly severe (16–25) and profound (26–75) ISS. However, the ISS in these patients did not correlate with the need for surgical intervention. A total of 24 (17%) patients with renal trauma were hypotensive (SBP < 90 mm Hg) on presentation and 50 (35%) had tachycardia (HR > 100 beats/minute) (Table 1).

Most patients with renal trauma (89%) had other concomitant organ injuries. Only 16 (11%) patients had isolated renal trauma. Splenic (30%) and liver (27%) injuries were most associated with renal trauma (Fig. 3).

Operative management (OM) for the kidney was performed in 10 patients. Seven of the 144 (5%) patients had nephrectomy. Of the seven patients who underwent nephrectomy, five were operated within the first 24 h of admission while the remaining two had delayed nephrectomy (beyond 24 h, exact timing unknown). Three patients underwent primary repair of renal injury (renorrhaphy).

Three patients had grade V trauma; all underwent nephrectomy due to haemodynamic instability. One fourth of patients with grade IV trauma (n = 7) underwent OM; 4 patients underwent nephrectomy, none due to haemodynamic instability; 3 had primary repair of the renal injury (Table 2).

The 30-day in-hospital mortality in patients with renal trauma was 17% (24/144). The mortality in patients with renal trauma as per AAST grades is shown in Table 2. However, due to overall small number of patients with renal trauma with very few patients having isolated renal trauma, its contribution to the mortality could not be determined.

We found renal trauma to be present in around 1% of patients admitted for trauma and 13% of patients with abdominal trauma in this Indian cohort. This is comparable to global trauma literature with renal trauma present in around 0.5–5% of patients admitted for trauma and 8–20% of patients with abdominal trauma [4, 6, 7, 18].

Most patients were managed conservatively (NOM) with only 7 (5%) undergoing nephrectomy. Nephrectomies were only performed in patients with grade IV & V renal trauma. Indian centres have previously reported nephrectomy rates of 12–16%, with those in grade V approaching 90% [12, 19]. A study from South Africa, a setting similar to the Indian LMIC context, demonstrated high nephrectomy rates of 40% for grade IV and 89% for grade V in predominantly blunt renal trauma [20]. Contrary to this, another South African study from a tertiary level major trauma centre utilising endovascular and endourological interventions for trauma management, demonstrated nephrectomy rates of 10.5% for grade IV and 25% for grade V patients with blunt renal trauma [21]. A genitourinary trauma study by the AAST demonstrated nephrectomy rates of 15% for grade IV and 62% for grade V [10], and a Canadian study by Mann et al. demonstrated only a 4% nephrectomy rate for high-grade renal trauma [22]. As compared to HICs and LMIC setups practicing minimally invasive endovascular and endourological techniques, the nephrectomy rate was higher in our cohort for grade V renal trauma. However, a true comparison may not be feasible due to the small number of patients with grade V renal trauma in our cohort and all of these patients being hemodynamically unstable, at least upon arrival. Further, while angioembolisation was available in all the centres included in this study, utilisation of these resources is not recorded in our dataset. Additionally, access to these resources in the emergency trauma setting can be variable based on time of day and existing case volume.

Renal trauma often occurs as a part of polytrauma. 89% of renal trauma patients in this study had concomitant injuries. The most common organs affected were the spleen and the liver. This is comparable to the literature around the world with 80–95% patients having associated organ injuries [7, 23, 24]. We observed a relatively high mortality in patients with low-grade renal trauma and other concomitant injuries. This high mortality was likely due to serious concomitant injuries, as isolated renal trauma in our cohort was rare.

The mean age of patients afflicted with renal trauma in this study was 28 years. Age demonstrated a unimodal distribution with young adults being the most affected. We also observed a male predominance. Blunt injuries, particularly RTIs and falls, were the most common mechanism . This is similar to the global literature, wherein patients afflicted with renal trauma have been predominantly young, with a mean age between 30 and 40; mostly male, reflecting 70–90% of cases; and due to blunt trauma mechanism, particularly road traffic injury [7, 23, 25]. Renal trauma was observed mainly in pedestrians and motorcyclists among the RTIs. Pedestrians and motorcyclists are vulnerable to renal trauma, and these injuries may be unique to LMIC settings like India [10] and may form basis for future work.

A strength of this analysis is the large dataset, representing multiple level 1 public urban healthcare centres across India, allowing a more complete representation of the renal trauma patient profile, injury grade, and management strategies employed.

A limitation of our analysis is the limited information on the use of endovascular therapies. Additional research is needed to understand the impact of the availability of endovascular therapy, or its absence, on the management of high-grade renal trauma in the Indian context.

Renal trauma is present in 1% of patients admitted for trauma and 13% of patients with abdominal trauma. Most renal trauma patients were managed nonoperatively. Most patients (89%) with renal trauma had concomitant injuries. The renal trauma profile from this large cohort may be generalisable to other urban healthcare centres in India and urban contexts in other LMICs.