Author's Accepted Manuscript Demographics of Pediatric Renal Trauma Gwen M. Grimsby , Bryan Voelzke , James Hotaling , Mathew D. Sorensen , Martin Koyle , Micah A. Jacobs
PII: DOI: Reference:
S0022-5347(14)03717-3 10.1016/j.juro.2014.05.103 JURO 11527
To appear in: The Journal of Urology Accepted Date: 23 May 2014 Please cite this article as: Grimsby GM, Voelzke B, Hotaling J, Sorensen MD, Koyle M, Jacobs MA, Demographics of Pediatric Renal Trauma, The Journal of Urology® (2014), doi: 10.1016/ j.juro.2014.05.103. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
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Demographics of Pediatric Renal Trauma
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Running head: Pediatric Renal Trauma
7
Gwen M. Grimsby MD1, Bryan Voelzke MD2, James Hotaling MD3, Mathew D.
8
Sorensen MD, MS2,4, Martin Koyle MD5, Micah A. Jacobs MD,MPH1 1
Division of Pediatric Urology, Department of Urology, UT Southwestern
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Medical Center, Dallas, TX 2
Department of Urology, University of Washington School of Medicine, Seattle, WA 3
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Center for Reconstructive Urology and Men’s Health, University of Utah
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Salt Lake City, UT 4
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Division of Urology, Department of Veteran Affairs Medical Center, Seattle, WA 5
University of Toronto, Hospital for Sick Children, Toronto, Canada
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Correspondence: Micah A. Jacobs MD, MPH Center for Pediatric Urology Children’s Medical Center 1935 Medical District Drive, MC F4.04 Dallas, TX 75235 Email: [email protected] P: 214-456-2444 F: 214-456-0126
27 28
Key words: trauma; wounds and injury; trauma center; pediatric; kidney
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Abstract Purpose: There is a lack of national data describing the demographics and nature of
31
pediatric renal trauma. The goal of this study was to use the National Trauma Data Bank
32
to analyze the method and grade of renal injury, demographic, and treatment
33
characteristics of pediatric renal trauma patients.
34
Materials and Methods: Renal injuries were identified by Abbreviated Injury Scale
35
codes and converted to American Association for the Surgery of Trauma (AAST) renal
36
injury grades. Patients were stratified by age (0-1, 2-4, 5-14, and 15-18) for more
37
specific analyses of mechanism and grade of injury. Data reviewed included mechanism
38
and grade of renal injury, demographics, and setting and type of treatment.
39
Results: 2213 pediatric renal injuries were converted to AAST grade. Mean age at time
40
of injury was 13.7 years old (SD 4.4) with 2089 (94%) patients between the ages of 5 and
41
18. 79% of injuries were grades I, II or III. Penetrating injury accounted for less than
42
10% of all pediatric renal injuries. A majority of patients were admitted to university
43
hospitals (57%) with a dedicated trauma service (73%) and only 12% of patients were
44
admitted to a children’s hospital. 122 nephrectomies were performed (5.5%).
45
Conclusion: A majority of renal trauma in children is low grade, blunt in nature, more
46
common in children over the age of 5, and the vast majority treated at adult hospitals.
47
Though a majority of patients were managed conservatively, the rate of
48
nephrectomy was 3 times higher at adult hospitals versus pediatric centers.
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Introduction Trauma is the single highest cause of death and acquired disability in children[1].
51
The most common injured organ in the urinary system in children is the kidney, which is
52
more frequent than the spleen, liver, pancreas, bowel, lung, heart or great vessels[2-4]. It
53
has been theorized that children are at greater risk of renal injury than adults due to
54
several anatomical differences[2]. These differences include less peri-renal fat,
55
proportionally smaller abdominal muscles, and lack of ossification of the rib cage all of
56
which provide less protection to the kidney as well as large kidney size proportional to
57
surrounding organs, lower abdominal position, and retained fetal lobulations which may
58
predispose to parenchymal disruption[2, 5].
SC
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Despite these theories, statistics for age at occurrence as well as type and mechanism of renal injury in the pediatric population are sparse. Existing studies
61
indicate that pediatric renal trauma occurs in 10% to 20% of pediatric blunt abdominal
62
trauma [6, 7]. However, the number of patients in these studies is small with a low
63
percentage of high grade injuries. Due to the paucity of pediatric data, practice
64
guidelines rely on sparse information and many decisions made in the setting of pediatric
65
renal trauma are based on the larger adult renal trauma literature[8]. This deficiency
66
emphasizes the need for pediatric specific data.
EP
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67
TE D
60
The goal of this study was to describe the age at occurrence as well as mechanism
68
and grade of renal trauma in the pediatric population using the American College of
69
Surgeons National Trauma Data Bank® (NTDB). In addition, the demographic
70
predisposition for injury, the characteristics of the hospitals where patients presented for
71
treatment, and the nature of treatments were also evaluated. Through this data we hope
ACCEPTED MANUSCRIPT 4 72
to better define the grade and mechanism of renal trauma in the pediatric population as
73
well as the demographic risk factors for injury and characteristics of treating hospitals.
74
Methods A retrospective query of the NTDB was performed. The NTDB is a voluntary
RI PT
75
national database that has collected information on trauma from participant hospitals in
77
the United States and Puerto Rico since 2002. It is currently the largest registry of
78
trauma data in the United States containing more than 5 million records with
79
contributions from 805 hospitals including 33 Level I or Level II Pediatric only trauma
80
centers[9]. As this study used anonymous data only, it was exempt from institutional
81
review board approval.
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SC
76
Pediatric renal injuries from 2002 to 2007 were identified by Abbreviated Injury Scale (AIS) codes. AIS codes were then converted to American Association for the
84
Surgery of Trauma (AAST) renal injury grade by the method previously described by
85
Kuan et al[10] and conversion was performed with statistical software. Patient
86
characteristics analyzed included age, race, sex, and grade and mechanism of renal injury.
87
Injuries were defined as blunt or penetrating by the NTDB. Pediatric patients were
88
defined as patients 18 years or younger and were stratified by age (0-1, 2-4, 5-14, and 15-
89
18). In addition, hospital data examined included self-reported trauma level, admission
90
service, adult versus pediatric hospital, and university association. Finally, type of
91
treatment was analyzed including conservative management (patients who did not
92
require any intervention), minimally invasive treatment (e.g. embolization, endoscopic
93
procedure), or operative management occurring any time during the initial
94
hospitalization.
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Results Of the 3,247,955 patients available for analysis in the NTDB from 2002 to 2007, a total of 9,002 renal injuries could be converted to AAST grade from AIS code. Twenty
98
five percent (2213) of these patients were younger than 19 years of age and thus included
99
in this analysis. The mean age at time of injury was 13.7 years old (SD 4.4). The
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majority of the patients were male (66%) and Caucasian (62%), Table 1. Ninety four
101
percent of patients were between 5 and 18 years old and 57% of patients were over the
102
age of 14, Table 1. Mean length of stay (LOS) was 8.63 days (SD 10.8) and mean Injury
103
Severity Score (ISS) was 21.4 (SD 14.2), Table 1.
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Of the 2,213 injuries in the database, 1,753 (79%) were grades I, II or III, Table 1. There were 460 (21%) high grade injuries including 354 grade IV injuries and 106 grade
106
V injuries, Table 1. ISS increased with increasing grade of renal injury, Table 1.
107
Penetrating injury accounted for less than 10% of all pediatric renal injuries. There were
108
a higher number of penetrating injuries among African American (26%) and Hispanic
109
(20%) compared with Caucasian (3%) patients, as well as in males (89%) and those >14
110
years old (13%), Table 1. In addition, penetrating injuries made up 15% of high grade
111
trauma vs. 8% of low grade trauma.
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The majority of patients (79%) presented to a level I or level II trauma center,
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105
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Table 2. Eighty-eight percent of patients were admitted to an adult institution, over half
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of which were university hospitals. Only 12% of patients were admitted to a dedicated
115
children’s hospital. Even among patients 14, and in African American or Hispanic ethnicities. Eighty eight percent of patients
232
were treated at an adult hospital and 5.5% underwent nephrectomy. Patients treated at
233
adult hospitals were 3 times more likely to undergo a nephrectomy than those
234
treated at a pediatric hospital. Though this data suggests better organ preservation
235
at pediatric hospitals, future studies controlling for demographic information as
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well as grade and mechanism of renal trauma are needed to confirm these
237
observations.
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ACCEPTED MANUSCRIPT 12 References
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Control, C.f.D., National Vital Statistics Reports: Deaths: Leading causes for 2010. 2013. 62. Brown, S.L., J.S. Elder, and J.P. Spirnak, Are pediatric patients more susceptible to major renal injury from blunt trauma? A comparative study. J Urol, 1998. 160(1): p. 138-40. Morse, T.S., Renal injuries. Pediatr Clin North Am, 1975. 22(2): p. 379-91. Mendez, R., Renal trauma. J Urol, 1977. 118(5): p. 698-703. Kuzmarov, I.W., D.D. Morehouse, and S. Gibson, Blunt renal trauma in the pediatric population: a retrospective study. J Urol, 1981. 126(5): p. 648-9. McAninch, J.W., et al., Renal reconstruction after injury. J Urol, 1991. 145(5): p. 932-7. Buckley, J.C. and J.W. McAninch, The diagnosis, management, and outcomes of pediatric renal injuries. Urol Clin North Am, 2006. 33(1): p. 33-40, vi. Jacobs, M.A., et al., Conservative management vs early surgery for high grade pediatric renal trauma--do nephrectomy rates differ? J Urol, 2012. 187(5): p. 1817-22. Programs, A.C.o.S.T. National Trauma Data Bank Report. 2013 3/13/2014]; Available from: http://www.facs.org/trauma/ntdb/docpub.html. Kuan, J.K., et al., American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy, dialysis, and death in patients with blunt injury and nephrectomy for penetrating injuries. J Trauma, 2006. 60(2): p. 351-6. Gaines, B.A., Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma, 2009. 67(2 Suppl): p. S135-9. Wu, H.Y. and B.A. Gaines, Dirt bikes and all terrain vehicles: the real threat to pediatric kidneys. J Urol, 2007. 178(4 Pt 2): p. 1672-4. Surgeons, A.C.o. Creation of the National Sample: National Sample Project of the National Trauma Data Bank (NTDB), the American College of Surgeons. 2007 [cited 2014 May 7th]; Available from: http://www.facs.org/trauma/nsp/samplecreation.pdf. Hotaling, J.M., et al., A national study of trauma level designation and renal trauma outcomes. J Urol, 2012. 187(2): p. 536-41. Umbreit, E.C., J.C. Routh, and D.A. Husmann, Nonoperative management of nonvascular grade IV blunt renal trauma in children: meta-analysis and systematic review. Urology, 2009. 74(3): p. 579-82. Wessel, L.M., et al., Management of kidney injuries in children with blunt abdominal trauma. J Pediatr Surg, 2000. 35(9): p. 1326-30. Eassa, W., et al., Nonoperative management of grade 5 renal injury in children: does it have a place? Eur Urol, 2010. 57(1): p. 154-61. Rogers, C.G., et al., High-grade renal injuries in children--is conservative management possible? Urology, 2004. 64(3): p. 574-9. Broghammer, J.A., et al., Pediatric blunt renal trauma: its conservative management and patterns of associated injuries. Urology, 2006. 67(4): p. 823-7.
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Densmore, J.C., et al., Outcomes and delivery of care in pediatric injury. J Pediatr Surg, 2006. 41(1): p. 92-8; discussion 92-8. MacKenzie, E.J., et al., A national evaluation of the effect of trauma-center care on mortality. N Engl J Med, 2006. 354(4): p. 366-78. Odetola, F.O., et al., The relationship between the location of pediatric intensive care unit facilities and child death from trauma: a county-level ecologic study. J Pediatr, 2005. 147(1): p. 74-7. Krug, S.E. and D.W. Tuggle, Management of pediatric trauma. Pediatrics, 2008. 121(4): p. 849-54. Petrosyan, M., et al., Disparities in the delivery of pediatric trauma care. J Trauma, 2009. 67(2 Suppl): p. S114-9. Lippert, S.J., et al., Splenic conservation: variation between pediatric and adult trauma centers. J Surg Res, 2013. 182(1): p. 17-20. Bowman, S.M., et al., Hospital characteristics associated with the management of pediatric splenic injuries. JAMA, 2005. 294(20): p. 2611-7. Yeung, L.L. and S.B. Brandes, Contemporary management of renal trauma: differences between urologists and trauma surgeons. J Trauma Acute Care Surg, 2012. 72(1): p. 68-75; discussion 75-7. Buckley, J.C. and J.W. McAninch, Revision of current American Association for the Surgery of Trauma Renal Injury grading system. J Trauma, 2011. 70(1): p. 357.
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Table 1: Patient and Injury Characteristics (n=2213); n (%) 0-1 35 (2) Age 2-4 89 (4) 5-14 826 (37) 15-18 1263 (57) Male 1453 (66) Sex Female 760 (34) White 1369 (62) Race Black 400 (18) Hispanic 238 (11) Other 101 (5) Missing 80 (4) Grade N (%) Mean ISS (SD) I 653 (29.5) 18.31 (13.24) II 655 (29.6) 19.80 (14.27) III 445 (20.1) 20.56 (13.59) IV 354 (16.0) 26.30 (12.94) V 106 (4.8) 37.21 (12.40) Blunt 1991 (89.97) Mechanism Penetrating 215 (9.72) Other 7 (0.316) Mean ISS (SD) 21.4 (14.2) Hospital Course Nephrectomy 122 (5.5) Mortality 133 (6.0) LOS days (SD) 8.62 (10.8) Age Blunt n (%) Penetrating n (%) 0-1 30 (86) 5 (14) 2-4 82 (95) 4 (5) 5-14 785 (95) 38 (5) 15-18 1094 (87) 168 (13) Race White (non-Hispanic) 1320 (97) 43 (3) African-American 297 (74) 103 (26) Hispanic 189 (80) 48 (20) Sex Male 1259 (63) 192 (89) Female 732 (37) 23 (11) Injury Grade I 621 (96) 29 (4) II 602 (92) 52 (8) III 379 (85) 66 (15) IV 308 (87) 44 (13) V 81 (77) 24 (23) 81 (66) 41 (34) Nephrectomy
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Table 2: Hospital Characteristics; n (%) Trauma Center Level I 1245 (56.3) II 507 (22.9) III 35 (1.6) IV 9 (0.4) Missing 417 (18.8) Institution Type University 1258 (56.8) Non-university 952 (43.0) Missing 3 (0.1) Hospital Type Pediatric 257 (12) Adult 1956 (88) Region Midwest 576 (26) Northeast 129 (6) South 1132 (51) West 333 (15) Missing 43 (2) Admitting Service Medical 20 (0.90) Neuro 14 (0.63) Ortho 6 (0.27) Pediatric 299 (13) Trauma 2076 (73) Missing 112 (5) Other 136 (6)
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Open Operative Intervention N= 199 (9%) 14.3 (4.3)
59 (46) 69 (54)
629 (96.3) 607 (92.7) 377 (84.7) 232 (65.5) 42 (39.6)
19 (2.9) 30 (4.6) 24 (5.4) 43 (12.1) 11 (10.4)
1769 (88.8) 112 (52.1)
119 (6.0) 8 (3.7)
103 (5.2) 95 (44.2)
20.5 (14.1) 7.78 (9.9) 0 (0) 101 (5)
27.6 (13.9) 13.4 (11.8) 0 (0) 5 (4)
26.1 (13.7) 13.7 (15.8) 122 (61) 27 (14)
1649 (84) 238 (93)
118 (6) 9 (3)
189 (10) 10 (4)
1057 (85) 449 (89) 33 (94) 9 (100) 339
73 (6) 20 (4) 1 (3) 0 (0) 33
115 (9) 38 (7) 1 (3) 0 (0) 45
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Mean age, years (SD) Sex (n, %) Female Male Grade (n, %) I II III IV V Mechanism (n, %) Blunt Penetrating Hospital Course Mean ISS (SD) Mean LOS, days (SD) Nephrectomy (n, %) Mortality (n, %) Hospital Type (n,%) Adult Pediatric Trauma Level (n,%) I II III IV Missing
Table 3: Treatment Characteristics Conservative Minimally Invasive N=1887 N=127 (6%) (85%) 13.6 (4.4) 14.4 (4.0)
5 (0.8) 18 (2.7) 44 (9.9) 79 (22.3) 53 (50)
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Table 4: Hospital Characteristics and Nephrectomy Nephrectomy No Nephrectomy Hospital type; n (%) Pediatric hospital 6 (2) 251 (98) Adult hospital 116 (6) 1840 (94) Trauma level; n (%) I 69 (6) 1176 (94) II 29 (6) 478 (94) III 1 (3) 34 (97) IV 0 (0) 9 (100) Missing 23 259
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Key of Definitions for Abbreviations AAST - American Association for the Surgery of Trauma AIS - Abbreviated Injury Scale
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ISS – injury severity score LOS – length of stay NTDB - National Trauma Data Bank
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SD – standard deviation
PII: DOI: Reference:
S0022-5347(14)03717-3 10.1016/j.juro.2014.05.103 JURO 11527
To appear in: The Journal of Urology Accepted Date: 23 May 2014 Please cite this article as: Grimsby GM, Voelzke B, Hotaling J, Sorensen MD, Koyle M, Jacobs MA, Demographics of Pediatric Renal Trauma, The Journal of Urology® (2014), doi: 10.1016/ j.juro.2014.05.103. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
ACCEPTED MANUSCRIPT 1 1 2
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Demographics of Pediatric Renal Trauma
6
Running head: Pediatric Renal Trauma
7
Gwen M. Grimsby MD1, Bryan Voelzke MD2, James Hotaling MD3, Mathew D.
8
Sorensen MD, MS2,4, Martin Koyle MD5, Micah A. Jacobs MD,MPH1 1
Division of Pediatric Urology, Department of Urology, UT Southwestern
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5
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Medical Center, Dallas, TX 2
Department of Urology, University of Washington School of Medicine, Seattle, WA 3
12
Center for Reconstructive Urology and Men’s Health, University of Utah
14 15
Salt Lake City, UT 4
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Division of Urology, Department of Veteran Affairs Medical Center, Seattle, WA 5
University of Toronto, Hospital for Sick Children, Toronto, Canada
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Correspondence: Micah A. Jacobs MD, MPH Center for Pediatric Urology Children’s Medical Center 1935 Medical District Drive, MC F4.04 Dallas, TX 75235 Email: [email protected] P: 214-456-2444 F: 214-456-0126
27 28
Key words: trauma; wounds and injury; trauma center; pediatric; kidney
ACCEPTED MANUSCRIPT 2 29
Abstract Purpose: There is a lack of national data describing the demographics and nature of
31
pediatric renal trauma. The goal of this study was to use the National Trauma Data Bank
32
to analyze the method and grade of renal injury, demographic, and treatment
33
characteristics of pediatric renal trauma patients.
34
Materials and Methods: Renal injuries were identified by Abbreviated Injury Scale
35
codes and converted to American Association for the Surgery of Trauma (AAST) renal
36
injury grades. Patients were stratified by age (0-1, 2-4, 5-14, and 15-18) for more
37
specific analyses of mechanism and grade of injury. Data reviewed included mechanism
38
and grade of renal injury, demographics, and setting and type of treatment.
39
Results: 2213 pediatric renal injuries were converted to AAST grade. Mean age at time
40
of injury was 13.7 years old (SD 4.4) with 2089 (94%) patients between the ages of 5 and
41
18. 79% of injuries were grades I, II or III. Penetrating injury accounted for less than
42
10% of all pediatric renal injuries. A majority of patients were admitted to university
43
hospitals (57%) with a dedicated trauma service (73%) and only 12% of patients were
44
admitted to a children’s hospital. 122 nephrectomies were performed (5.5%).
45
Conclusion: A majority of renal trauma in children is low grade, blunt in nature, more
46
common in children over the age of 5, and the vast majority treated at adult hospitals.
47
Though a majority of patients were managed conservatively, the rate of
48
nephrectomy was 3 times higher at adult hospitals versus pediatric centers.
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SC
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30
ACCEPTED MANUSCRIPT 3 49
Introduction Trauma is the single highest cause of death and acquired disability in children[1].
51
The most common injured organ in the urinary system in children is the kidney, which is
52
more frequent than the spleen, liver, pancreas, bowel, lung, heart or great vessels[2-4]. It
53
has been theorized that children are at greater risk of renal injury than adults due to
54
several anatomical differences[2]. These differences include less peri-renal fat,
55
proportionally smaller abdominal muscles, and lack of ossification of the rib cage all of
56
which provide less protection to the kidney as well as large kidney size proportional to
57
surrounding organs, lower abdominal position, and retained fetal lobulations which may
58
predispose to parenchymal disruption[2, 5].
SC
M AN U
59
RI PT
50
Despite these theories, statistics for age at occurrence as well as type and mechanism of renal injury in the pediatric population are sparse. Existing studies
61
indicate that pediatric renal trauma occurs in 10% to 20% of pediatric blunt abdominal
62
trauma [6, 7]. However, the number of patients in these studies is small with a low
63
percentage of high grade injuries. Due to the paucity of pediatric data, practice
64
guidelines rely on sparse information and many decisions made in the setting of pediatric
65
renal trauma are based on the larger adult renal trauma literature[8]. This deficiency
66
emphasizes the need for pediatric specific data.
EP
AC C
67
TE D
60
The goal of this study was to describe the age at occurrence as well as mechanism
68
and grade of renal trauma in the pediatric population using the American College of
69
Surgeons National Trauma Data Bank® (NTDB). In addition, the demographic
70
predisposition for injury, the characteristics of the hospitals where patients presented for
71
treatment, and the nature of treatments were also evaluated. Through this data we hope
ACCEPTED MANUSCRIPT 4 72
to better define the grade and mechanism of renal trauma in the pediatric population as
73
well as the demographic risk factors for injury and characteristics of treating hospitals.
74
Methods A retrospective query of the NTDB was performed. The NTDB is a voluntary
RI PT
75
national database that has collected information on trauma from participant hospitals in
77
the United States and Puerto Rico since 2002. It is currently the largest registry of
78
trauma data in the United States containing more than 5 million records with
79
contributions from 805 hospitals including 33 Level I or Level II Pediatric only trauma
80
centers[9]. As this study used anonymous data only, it was exempt from institutional
81
review board approval.
M AN U
82
SC
76
Pediatric renal injuries from 2002 to 2007 were identified by Abbreviated Injury Scale (AIS) codes. AIS codes were then converted to American Association for the
84
Surgery of Trauma (AAST) renal injury grade by the method previously described by
85
Kuan et al[10] and conversion was performed with statistical software. Patient
86
characteristics analyzed included age, race, sex, and grade and mechanism of renal injury.
87
Injuries were defined as blunt or penetrating by the NTDB. Pediatric patients were
88
defined as patients 18 years or younger and were stratified by age (0-1, 2-4, 5-14, and 15-
89
18). In addition, hospital data examined included self-reported trauma level, admission
90
service, adult versus pediatric hospital, and university association. Finally, type of
91
treatment was analyzed including conservative management (patients who did not
92
require any intervention), minimally invasive treatment (e.g. embolization, endoscopic
93
procedure), or operative management occurring any time during the initial
94
hospitalization.
AC C
EP
TE D
83
ACCEPTED MANUSCRIPT 5 95 96
Results Of the 3,247,955 patients available for analysis in the NTDB from 2002 to 2007, a total of 9,002 renal injuries could be converted to AAST grade from AIS code. Twenty
98
five percent (2213) of these patients were younger than 19 years of age and thus included
99
in this analysis. The mean age at time of injury was 13.7 years old (SD 4.4). The
RI PT
97
majority of the patients were male (66%) and Caucasian (62%), Table 1. Ninety four
101
percent of patients were between 5 and 18 years old and 57% of patients were over the
102
age of 14, Table 1. Mean length of stay (LOS) was 8.63 days (SD 10.8) and mean Injury
103
Severity Score (ISS) was 21.4 (SD 14.2), Table 1.
M AN U
104
SC
100
Of the 2,213 injuries in the database, 1,753 (79%) were grades I, II or III, Table 1. There were 460 (21%) high grade injuries including 354 grade IV injuries and 106 grade
106
V injuries, Table 1. ISS increased with increasing grade of renal injury, Table 1.
107
Penetrating injury accounted for less than 10% of all pediatric renal injuries. There were
108
a higher number of penetrating injuries among African American (26%) and Hispanic
109
(20%) compared with Caucasian (3%) patients, as well as in males (89%) and those >14
110
years old (13%), Table 1. In addition, penetrating injuries made up 15% of high grade
111
trauma vs. 8% of low grade trauma.
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The majority of patients (79%) presented to a level I or level II trauma center,
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112
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105
113
Table 2. Eighty-eight percent of patients were admitted to an adult institution, over half
114
of which were university hospitals. Only 12% of patients were admitted to a dedicated
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children’s hospital. Even among patients 14, and in African American or Hispanic ethnicities. Eighty eight percent of patients
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were treated at an adult hospital and 5.5% underwent nephrectomy. Patients treated at
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adult hospitals were 3 times more likely to undergo a nephrectomy than those
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Control, C.f.D., National Vital Statistics Reports: Deaths: Leading causes for 2010. 2013. 62. Brown, S.L., J.S. Elder, and J.P. Spirnak, Are pediatric patients more susceptible to major renal injury from blunt trauma? A comparative study. J Urol, 1998. 160(1): p. 138-40. Morse, T.S., Renal injuries. Pediatr Clin North Am, 1975. 22(2): p. 379-91. Mendez, R., Renal trauma. J Urol, 1977. 118(5): p. 698-703. Kuzmarov, I.W., D.D. Morehouse, and S. Gibson, Blunt renal trauma in the pediatric population: a retrospective study. J Urol, 1981. 126(5): p. 648-9. McAninch, J.W., et al., Renal reconstruction after injury. J Urol, 1991. 145(5): p. 932-7. Buckley, J.C. and J.W. McAninch, The diagnosis, management, and outcomes of pediatric renal injuries. Urol Clin North Am, 2006. 33(1): p. 33-40, vi. Jacobs, M.A., et al., Conservative management vs early surgery for high grade pediatric renal trauma--do nephrectomy rates differ? J Urol, 2012. 187(5): p. 1817-22. Programs, A.C.o.S.T. National Trauma Data Bank Report. 2013 3/13/2014]; Available from: http://www.facs.org/trauma/ntdb/docpub.html. Kuan, J.K., et al., American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy, dialysis, and death in patients with blunt injury and nephrectomy for penetrating injuries. J Trauma, 2006. 60(2): p. 351-6. Gaines, B.A., Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma, 2009. 67(2 Suppl): p. S135-9. Wu, H.Y. and B.A. Gaines, Dirt bikes and all terrain vehicles: the real threat to pediatric kidneys. J Urol, 2007. 178(4 Pt 2): p. 1672-4. Surgeons, A.C.o. Creation of the National Sample: National Sample Project of the National Trauma Data Bank (NTDB), the American College of Surgeons. 2007 [cited 2014 May 7th]; Available from: http://www.facs.org/trauma/nsp/samplecreation.pdf. Hotaling, J.M., et al., A national study of trauma level designation and renal trauma outcomes. J Urol, 2012. 187(2): p. 536-41. Umbreit, E.C., J.C. Routh, and D.A. Husmann, Nonoperative management of nonvascular grade IV blunt renal trauma in children: meta-analysis and systematic review. Urology, 2009. 74(3): p. 579-82. Wessel, L.M., et al., Management of kidney injuries in children with blunt abdominal trauma. J Pediatr Surg, 2000. 35(9): p. 1326-30. Eassa, W., et al., Nonoperative management of grade 5 renal injury in children: does it have a place? Eur Urol, 2010. 57(1): p. 154-61. Rogers, C.G., et al., High-grade renal injuries in children--is conservative management possible? Urology, 2004. 64(3): p. 574-9. Broghammer, J.A., et al., Pediatric blunt renal trauma: its conservative management and patterns of associated injuries. Urology, 2006. 67(4): p. 823-7.
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Densmore, J.C., et al., Outcomes and delivery of care in pediatric injury. J Pediatr Surg, 2006. 41(1): p. 92-8; discussion 92-8. MacKenzie, E.J., et al., A national evaluation of the effect of trauma-center care on mortality. N Engl J Med, 2006. 354(4): p. 366-78. Odetola, F.O., et al., The relationship between the location of pediatric intensive care unit facilities and child death from trauma: a county-level ecologic study. J Pediatr, 2005. 147(1): p. 74-7. Krug, S.E. and D.W. Tuggle, Management of pediatric trauma. Pediatrics, 2008. 121(4): p. 849-54. Petrosyan, M., et al., Disparities in the delivery of pediatric trauma care. J Trauma, 2009. 67(2 Suppl): p. S114-9. Lippert, S.J., et al., Splenic conservation: variation between pediatric and adult trauma centers. J Surg Res, 2013. 182(1): p. 17-20. Bowman, S.M., et al., Hospital characteristics associated with the management of pediatric splenic injuries. JAMA, 2005. 294(20): p. 2611-7. Yeung, L.L. and S.B. Brandes, Contemporary management of renal trauma: differences between urologists and trauma surgeons. J Trauma Acute Care Surg, 2012. 72(1): p. 68-75; discussion 75-7. Buckley, J.C. and J.W. McAninch, Revision of current American Association for the Surgery of Trauma Renal Injury grading system. J Trauma, 2011. 70(1): p. 357.
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Table 1: Patient and Injury Characteristics (n=2213); n (%) 0-1 35 (2) Age 2-4 89 (4) 5-14 826 (37) 15-18 1263 (57) Male 1453 (66) Sex Female 760 (34) White 1369 (62) Race Black 400 (18) Hispanic 238 (11) Other 101 (5) Missing 80 (4) Grade N (%) Mean ISS (SD) I 653 (29.5) 18.31 (13.24) II 655 (29.6) 19.80 (14.27) III 445 (20.1) 20.56 (13.59) IV 354 (16.0) 26.30 (12.94) V 106 (4.8) 37.21 (12.40) Blunt 1991 (89.97) Mechanism Penetrating 215 (9.72) Other 7 (0.316) Mean ISS (SD) 21.4 (14.2) Hospital Course Nephrectomy 122 (5.5) Mortality 133 (6.0) LOS days (SD) 8.62 (10.8) Age Blunt n (%) Penetrating n (%) 0-1 30 (86) 5 (14) 2-4 82 (95) 4 (5) 5-14 785 (95) 38 (5) 15-18 1094 (87) 168 (13) Race White (non-Hispanic) 1320 (97) 43 (3) African-American 297 (74) 103 (26) Hispanic 189 (80) 48 (20) Sex Male 1259 (63) 192 (89) Female 732 (37) 23 (11) Injury Grade I 621 (96) 29 (4) II 602 (92) 52 (8) III 379 (85) 66 (15) IV 308 (87) 44 (13) V 81 (77) 24 (23) 81 (66) 41 (34) Nephrectomy
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Table 2: Hospital Characteristics; n (%) Trauma Center Level I 1245 (56.3) II 507 (22.9) III 35 (1.6) IV 9 (0.4) Missing 417 (18.8) Institution Type University 1258 (56.8) Non-university 952 (43.0) Missing 3 (0.1) Hospital Type Pediatric 257 (12) Adult 1956 (88) Region Midwest 576 (26) Northeast 129 (6) South 1132 (51) West 333 (15) Missing 43 (2) Admitting Service Medical 20 (0.90) Neuro 14 (0.63) Ortho 6 (0.27) Pediatric 299 (13) Trauma 2076 (73) Missing 112 (5) Other 136 (6)
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Open Operative Intervention N= 199 (9%) 14.3 (4.3)
59 (46) 69 (54)
629 (96.3) 607 (92.7) 377 (84.7) 232 (65.5) 42 (39.6)
19 (2.9) 30 (4.6) 24 (5.4) 43 (12.1) 11 (10.4)
1769 (88.8) 112 (52.1)
119 (6.0) 8 (3.7)
103 (5.2) 95 (44.2)
20.5 (14.1) 7.78 (9.9) 0 (0) 101 (5)
27.6 (13.9) 13.4 (11.8) 0 (0) 5 (4)
26.1 (13.7) 13.7 (15.8) 122 (61) 27 (14)
1649 (84) 238 (93)
118 (6) 9 (3)
189 (10) 10 (4)
1057 (85) 449 (89) 33 (94) 9 (100) 339
73 (6) 20 (4) 1 (3) 0 (0) 33
115 (9) 38 (7) 1 (3) 0 (0) 45
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Mean age, years (SD) Sex (n, %) Female Male Grade (n, %) I II III IV V Mechanism (n, %) Blunt Penetrating Hospital Course Mean ISS (SD) Mean LOS, days (SD) Nephrectomy (n, %) Mortality (n, %) Hospital Type (n,%) Adult Pediatric Trauma Level (n,%) I II III IV Missing
Table 3: Treatment Characteristics Conservative Minimally Invasive N=1887 N=127 (6%) (85%) 13.6 (4.4) 14.4 (4.0)
5 (0.8) 18 (2.7) 44 (9.9) 79 (22.3) 53 (50)
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Table 4: Hospital Characteristics and Nephrectomy Nephrectomy No Nephrectomy Hospital type; n (%) Pediatric hospital 6 (2) 251 (98) Adult hospital 116 (6) 1840 (94) Trauma level; n (%) I 69 (6) 1176 (94) II 29 (6) 478 (94) III 1 (3) 34 (97) IV 0 (0) 9 (100) Missing 23 259
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Key of Definitions for Abbreviations AAST - American Association for the Surgery of Trauma AIS - Abbreviated Injury Scale
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ISS – injury severity score LOS – length of stay NTDB - National Trauma Data Bank
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SD – standard deviation
