Davis Kimberly A, Reed R Lawrence, Santaniello John, Abodeely Adam, Esposito Thomas J, Poulakidas Stathis J, Luchette Fred A
Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, 2160 S. First Avenue, 110-3277, Maywood, IL 60153, USA.
J Trauma. 2006 Jan;60(1):164-9; discussion 169-70. doi: 10.1097/01.ta.0000199924.39736.36.
Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma.
This is a retrospective review of renal injuries admitted over a 12-year period to a Level I trauma center.
Ninety-seven patients (73% male) sustained a kidney injury (mean age, 27 +/- 16; mean Injury Severity Score, 13 +/- 10). Of the 72 blunt trauma patients, 5 patients (7%) underwent urgent nephrectomy, 3 (4%) had repair and/or stenting, and 89% were observed despite a 29% laparotomy rate for associated intraabdominal injuries in this group. Twenty-five patients with penetrating trauma underwent eight nephrectomies (31%), one partial nephrectomy, and two renal repairs. Regardless of the mechanism of injury, patients requiring nephrectomy were in shock, had a higher 24-hour transfusion requirement, and were more likely to have a high-grade renal laceration (all p < 0.05). Bluntly injured patients requiring nephrectomy had more concurrent intraabdominal injuries (p < 0.0001). Overall, patients after penetrating trauma were more severely injured, had higher 24-hour transfusion requirements, and a higher nephrectomy rate (all p < 0.05). Despite a higher injury severity in the penetrating group, however, mortality was higher in the bluntly injured group (p < 0.0001). Univariate predictors for nephrectomy included: revised trauma score, injury severity score, Glasgow Coma Scale score, shock on presentation, renal injury grade, and 24-hour transfusion requirement. No patient with a mild or moderate renal injury required nephrectomy, whereas 6 of 12 (50%) grade 4 injuries and 7 of 8 (88%) grade 5 injuries required nephrectomy. Multiple logistic regression analysis confirmed penetrating injury, renal injury grade, and Glasgow Coma Scale score as predictive of nephrectomy.
Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.
血流动力学稳定的实体器官损伤患者的初始治疗为非手术治疗。因此，早期识别那些可能需要手术干预的损伤是关键。我们试图确定创伤后肾切除需求的预测因素。
这是对一家一级创伤中心12年期间收治的肾损伤患者的回顾性研究。
97例患者（73%为男性）遭受肾损伤（平均年龄27±16岁；平均损伤严重度评分13±10）。在72例钝性创伤患者中，5例（7%）接受了急诊肾切除术，3例（4%）进行了修复和/或支架置入，尽管该组因相关腹部损伤而行剖腹手术的比例为29%，但89%的患者接受了观察。25例穿透性创伤患者中，8例（31%）接受了肾切除术，1例接受了部分肾切除术，2例进行了肾脏修复。无论损伤机制如何，需要肾切除的患者均处于休克状态，24小时输血需求量更高，且更可能存在高级别肾裂伤（所有p<0.05）。钝性创伤后需要肾切除的患者合并腹部损伤更多（p<0.0001）。总体而言，穿透性创伤患者损伤更严重，24小时输血需求量更高，肾切除率更高（所有p<0.05）。然而，尽管穿透性创伤组损伤严重程度更高，但钝性创伤组的死亡率更高（p<0.0001）。肾切除的单因素预测因素包括：修订创伤评分、损伤严重度评分、格拉斯哥昏迷量表评分、入院时休克、肾损伤分级和24小时输血需求量。轻度或中度肾损伤患者均无需肾切除，而12例4级损伤患者中有6例（50%）和8例5级损伤患者中有7例（88%）需要肾切除。多因素逻辑回归分析证实穿透性损伤、肾损伤分级和格拉斯哥昏迷量表评分可预测肾切除。
总体而言，损伤严重程度、肾损伤分级严重程度、血流动力学不稳定和输血需求量可预测钝性和穿透性创伤后的肾切除。穿透性损伤后肾切除的可能性更大。
