title: Conservative management vs early surgery for high grade pediatric renal trauma--do nephrectomy rates differ?
abstract: OBJECTIVE
  Guidelines for management of pediatric high grade renal injuries are currently based on limited pediatric data and algorithms from adults, for whom initial nonoperative management is associated with decreased nephrectomy risk. Using a national database, we compared nephrectomy rates between children with high grade renal injury managed conservatively and those undergoing early surgical intervention.
  
  
  METHODS
  All children with high grade renal injuries were identified in the National Trauma Data Bank®. High grade renal injuries were defined as American Association for the Surgery of Trauma grade IV or V renal injuries. After excluding fatalities within 24 hours of hospitalization, 419 pediatric patients comprised our study cohort. A total of 81 patients underwent early (within 24 hours of hospitalization) surgical intervention, while 338 were initially treated conservatively. Using stratified analysis with adjustment for relevant covariates, we compared nephrectomy rates between these groups.
  
  
  RESULTS
  Nephrectomy was performed less often in patients treated conservatively (RR 0.24, 95% CI 0.16 to 0.36, adjusted for age, renal injury grade and injury mechanism). The decreased risk of nephrectomy was more marked among children with grade IV vs grade V renal injuries (adjusted RR 0.16, 95% CI 0.08 to 0.23). Multiple procedures were more common in patients initially observed. Of pediatric patients with grade IV and V renal injuries 11% still underwent nephrectomy.
  
  
  CONCLUSIONS
  Conservative management of high grade renal injuries is common in children. Although mechanism of injury and renal injury grade impact initial clinical management decisions, the risk of nephrectomy was consistently decreased in children with high grade renal trauma managed conservatively regardless of injury characteristics.
authors.affiliation: Children's Medical Center Dallas, 2350 Stemmons Frwy., Suite D-4300, Mail Code F4.04, Dallas, Texas 75207, USA. micah.jacobs@aya.yale.edu
authors.forename: Micah A
authors.initials: MA
authors.lastname: Jacobs
authors.forename: James M
authors.initials: JM
authors.lastname: Hotaling
authors.forename: Beth A
authors.initials: BA
authors.lastname: Mueller
authors.forename: Martin
authors.initials: M
authors.lastname: Koyle
authors.forename: Frederick
authors.initials: F
authors.lastname: Rivara
authors.forename: Bryan B
authors.initials: BB
authors.lastname: Voelzke
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007668:Kidney / Q000293:injuries*; D008297:Male; D009392:Nephrectomy / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013997:Time Factors; D015599:Trauma Severity Indices; D014949:Wounds, Nonpenetrating / Q000601:surgery*