title: Grade IV renal trauma management. A revision of the AAST renal injury grading scale is mandatory.
abstract: BACKGROUND
  The AAST renal injury grading scale is currently the most important variable predicting the need for kidney repair or removal, morbidity and mortality after blunt or penetrating kidney injuries. The 2011 revised version included renal pelvis, uretero-pelvic junction and segmental vascular injuries as grade IV, limiting grade V to severe hilar injuries. However, patients requiring surgery cannot be properly identified because of hemodynamic instability due to grade IV renal injuries. This study proposes an add-on for the AAST grade IV renal injury scale to improve the management of these patients.
  
  
  METHODS
  We searched the Medline and Scopus databases up to September 2014. Searches were not restricted by date, language or publication status. Pediatric studies were excluded.
  
  
  RESULTS
  71 articles were found, 57 were pertinent, including 6 directly related to the topic. 3 risk factors were identified to be associated with surgery for hemodynamic instability: perirenal hematoma >3.5 cm, intravascular contrast extravasation and medial renal laceration. Presence of two or more of these criteria has been validated in two other studies to predict the need for intervention. Patients with >25 % devascularized fragments also have poor prognosis and should be treated more aggressively.
  
  
  CONCLUSIONS
  These elements should be included in future classification reassessment to efficiently determine the time for surgery in grade IV renal traumas, generally leading to nephrectomy.
authors.affiliation: Department of Urology, Val de Grace Military Hospital, 74 boulevard de Port Royal, 75005, Paris, France. p.chiron@laposte.net.
authors.forename: P
authors.identifier: http://orcid.org/0000-0001-5040-6955
authors.initials: P
authors.lastname: Chiron
authors.affiliation: Department of Thoracic and General Surgery, Percy Military Hospital, 101, avenue Henri Barbusse, 92140, Clamart, France.|6th Airportable Surgical Unit, French Army Health Service, Paris, France.
authors.forename: E
authors.initials: E
authors.lastname: Hornez
authors.affiliation: Department of Thoracic and General Surgery, Percy Military Hospital, 101, avenue Henri Barbusse, 92140, Clamart, France.
authors.forename: G
authors.initials: G
authors.lastname: Boddaert
authors.affiliation: Department of Urology, Val de Grace Military Hospital, 74 boulevard de Port Royal, 75005, Paris, France.
authors.forename: M
authors.initials: M
authors.lastname: Dusaud
authors.affiliation: Department of Urology, Val de Grace Military Hospital, 74 boulevard de Port Royal, 75005, Paris, France.
authors.forename: Y
authors.initials: Y
authors.lastname: Bayoud
authors.affiliation: Department of Urology, Val de Grace Military Hospital, 74 boulevard de Port Royal, 75005, Paris, France.
authors.forename: B
authors.initials: B
authors.lastname: Molimard
authors.affiliation: Department of Urology, Val de Grace Military Hospital, 74 boulevard de Port Royal, 75005, Paris, France.
authors.forename: F R
authors.initials: FR
authors.lastname: Desfemmes
authors.affiliation: Department of Urology, Val de Grace Military Hospital, 74 boulevard de Port Royal, 75005, Paris, France.
authors.forename: X
authors.initials: X
authors.lastname: Durand
mesh_terms: D002965:Classification; D019468:Disease Management; D006801:Humans; D015601:Injury Severity Score; D007668:Kidney / Q000293:injuries / Q000601:surgery; D009392:Nephrectomy / Q000379:methods*; D018579:Patient Selection; D018570:Risk Assessment; D015599:Trauma Severity Indices; D014949:Wounds, Nonpenetrating / Q000145:classification / Q000175:diagnosis / Q000601:surgery
keywords: AAST classification; Grade IV; Renal trauma; Revision