Renal Trauma With Posttraumatic
Hypertension
in a Neonate
By Yehezkel G. Caine, Scott Fields, Hubert Rakotomalala, Yigal Shvil, Shmuel Katz, and Medad Schiller Jerusalem, Israel 0 We report a case of renal trauma followed by hypertension and spontaneous recovery in 8 Z-week-old girl involved in 8 road 8ccident. Copyright
o 1992 by W.B. Saunders Company
INDEX WORDS: Renal trauma, neonatal.
R
ENAL TRAUMA as a result of involvement in accidents is fairly common in children,*‘3 but this apparently does not apply to the neonate. This is probably due to the lack of exposure. CASE REPORT A 2-week-old girl, weighing 3,650 g, was admitted to the emergency room following a road accident in which her parents were seriously injured. (No data are available regarding the mechanism of injury.) On admission she was fully conscious and physical examination was unremarkable. Blood count showed a hemoglobin of 17 g%. She was admitted for observation. During the night of admission, a few drops of blood were found in the vulvar region but no lacerations could be found. Repeat physical examination was negative. About 12 hours later the baby became progressively tachypneic, tachycardic, and red blood cells (RBCs) appeared in the urine, followed by frank hematuria and a drop in hemoglobin initially to 15.2 g%, and in the following hours to 10 g%, necessitating a transfusion of 40 mL of packed cells. Physical examination then showed marked sensitivity in the left upper quadrant of the abdomen and left flank. Biochemistry showed a serum Na 132 mmol/L, glucose 11.5 mmol/L, urea 9.1 mmol/L, alanine aminotransferase 520 IU, alkaline phosphatase 280 IU, and lactate dehydrogenase 3,400 IU. An intravenous pyelogram (IVP) with tomography showed normal right kidney morphology and excretion but no kidney was demonstrated on the left (Fig 1). Ultrasound (US) showed a normal right kidney. The left kidney was markedly enlarged and edematous with a fluid collection around the lower pole (Fig 2). At this point, with obvious left renal damage, an angiogram was considered. Due to the fact that more than 24 hours had passed since the injury, the potential for kidney salvage, if it was a vascular injury (due to a long warm ischemic time as well as very small vessels), was so slight that it didn’t justify the possible complications of angiography in a neonate. Therefore, it was decided to follow her clinically and sonographically. During the following days her condition remained stable. She was active, ate well, and showed no signs of other problems. Repeated US showed no expansion of the hematoma. The hematuria subsided and within a few days the US showed a decrease in the size of the hematoma. On the fifth day her blood pressure started increasing to 95/60 and continued to rise to 125/95 by the 10th day. Repeat IVP was
From the Departments of Pediabic Surgery, Radiology, and Pediatrics, Hadassah University Hospital, Jerusalem, Israel. Address reprint requests to Yehezkel G. Caine, MD, Department of Pedianic Sutge?y, Hadassah University Hospital, Kilyat Hadassah, Ein Karem, PO Box 12000, Jerusalem 91 120, Israel. Copyright o 1992 by W.B. Saunders Company 0022-346819212704~0027$03.0010 520
essentially the same as the original one. Fundus examinations were within normal limits. A DTPA renal scan showed delayed uptake and a smaller image of the left kidney when compared with the right. Because there was no evidence of target organ involvement (ie, electrocardiogram, fundoscopy, chest x-ray, and urinalysis) and no other side effects of the hypertension were found, it was felt that the potential complications and side effects of suitable antihypertensive agents (ie, Captopril), at this stage, outweighed the benefits. A conservative, nonphatmacological approach was selected with close monitoring for signs of deterioration or side effects. Blood pressure was measured frequently with repeated fundus and urine examinations. Renal size was assessed by US. Her blood pressure remained high for about 2 months, fluctuating about values of 100 to 130/70 to 90, yet with no evidence of target organ involvement or side effects. It then began to subside spontaneously, returning by the fourth month to normal values for her age at that point. US at 6 weeks (Fig 3) showed normal-sized kidneys on both sides. An IVP at 4 months (Fig 4) showed normal excretion from both kidneys. Examinations at 6 months and 1 year were completely normal.
DISCUSSION
To the best of our knowledge this is the first reported case of renal trauma in the neonate. Mendez, in his extensive review of renal trauma in 1977,’ refers to a case of an infant (age not given) in whom congenital bilateral ureteropelvic strictures with hydronephrosis became manifest due to anuria following an accident (no details are given in this personal communication by P. Peters). Trauma is the most common cause of death and injury in children aged 1 to 14 years,‘.3 but for obvious reasons trauma, especially road accidents, is very rare in the neonate. Blunt trauma of the kidney is the second most common injury in multiply injured children (after central nervous system injury).1-3 This is attributed to a number of factors that combine to give the child less protection than the adult.4 The management of blunt renal trauma continues to remain controversial in those cases with evidently severe damage to the kidney but an otherwise stable patient. Cass? found that in the more severe renal injuries (laceration, rupture, and vascular pedicle injuries) there was a surgery rate of 17% to 70% with a renal loss rate of 5% to 40%. In neither of his reviews, nor in others,‘.2.4 was there a clear relationship between the surgery rate and the renal salvage rate, with the possible exception of true unilateral pedicle injuries during the first 4 to 12 hours.’ Forty percent to 70% of children with kidney trauma have associated injuries,3*7with up to 33% requiring laparotomies and other surgery for these injuries.’ In the Journal of Pediatric Surgery,
Vol27, No 4 (April), ‘1992: pp 520-522
POSJTRAUMATIC
RENAL-VASCULAR
HYPERTENSION
521
Fig 3. US at 6 weeks showing a normal-sized kidney (bipolar diemeter of 4.5 cm) with complete resolution of the perirenal hematoma and edema.
Fig 1. R/P/CT shortly after admission, showing good uptake in the right kidney but no evidence of uptake in the left.
others for whom there were no other indications for surgery, the indications for exploring the kidney were: deteriorating vital signs, expanding renal mass, septic complications, and persistent significant hematuria.6r7 Diseased and anomalous kidneys are seemingly more prone to trauma,‘x8 with 7% to 17% of the kidneys injured in trauma showing a congenital anomaly.13738 In the present case there was no evidence of concurrent renal disease and her stable clinical condition precluded the need for surgical intervention.
Fig 2. US of the left kidney shortly sfter admission, showing merked enlargement (bipolar diameter of 7 cm), edema, and perirenal hematoms.
Radiological evaluation of the patient has a bearing on the clinical decision. Mostly the evaluation is by IVP with tomography and US.2.9Computed tomography (CT) scans are very useful’ and are becoming more prevalent, although in trauma cases, such as the present are, the recurrent exposure of the neonate to radiation with repeated x-rays, and especially CT scans, can be quite significant and should be considered carefully. Angiography is an important and useful investigation in suspected vascular pedicle damage, but in children, and especially in small infants, it may be very difficult and fraught with complications and should be avoided if possible.* Where available, digital subtraction angiography can be used as a substitute.’ In this case, as noted, we felt that a conservative approach, avoiding potentially dangerous investiga-
Fig 4. tion.
IVP et 4 months showing good bilateral uptake and excre-
CAINE ET AL
522
and surgery, was justified in view of the small chance of kidney salvage with a warm ischemic time of over 24 hours and very small vessels. So as to facilitate serial objective imaging and avoid radiation, US rather than CT was selected for serial follow-up. This showed a nonexpanding hematoma that spontaneously resolved over a period of a few weeks. Coupled with a renal scan showing perfusion of the kidney (at about the time that hypertension set in) we felt that close observation was paying off. Ultimately the kidney recovered completely as shown by the normal IVP and return to normotensive blood pressure. Renovascular hypertension in the neonate has been reported with increasing frequency in the literature. In addition to congenital diseases causing hypertension (eg, coarctation of the aorta, fibromuscular dysplasia, renal artery stenosis),“-” it has been recognized as a complication of umbilical artery catheterization causing renal artery thrombosis.‘0.13.14We have not found any reports of hypertension in the neonate due to renal trauma, but there is no reason to expect a different response to parenchymal damage from that found in older children or adults. The question is one of whether to treat the hypertension, or not, and if so at what stage. The second Task Force on Blood Pressure Control in Children-1987’s proposed a number of guidelines for the initiation of pharmacotherapy. They also raised a number of serious questions and reservations about the use of antihypertensive medication in children in whom nonpharmacological control of the hypertension might be achieved. Their indications for the initiation of antihypertensive drugs
tions
are: (1) significant diastolic hypertension (as defined in their guidelines); (2) evidence of target organ injury; and (3) symptoms or signs related to elevated blood pressure. In this case the blood pressure fell within the range of significant systolic hypertension for the age group, and at times within the severe hypertension group, as did the diastolic pressure. At no time did she show evidence of target organ involvement or other side effects. On the other hand, previous experience’* has shown spontaneous resolution of renovascular hypertension in certain cases. Experience with Captopril (the drug of choice in renovascular hypertension) in neonates has shown that although it is effective in reducing blood pressure, its use has been associated with potentially severe side effects, such as hypotension, renal failure, oliguria, subtle seizures, lethargy, In the balance, therefore, we elected to and apnea. 16.17 wait while closely following her. This with the intention of treating her medically, or performing a nephrectomy, at the first indication further increase in blood pressure or of damage to a target ‘organ. Within a few weeks the blood pressure had leveled off, and decreased rapidly following that. In the light of our experience in this case, as well as that of others,” we feel that the neonate has a reasonable chance for recovery of kidney function, even when severely damaged, with spontaneous resolution of associated hypertension. Medication, in view of its potential for serious side effects in the neonate, should be considered individually and according to the circumstances.
REFERENCES 1. Mendez R: Renal trauma. J Ural 118698703,1977 2. Livne PM, Gonzales ET: Genitourinary trauma in children. Urol Clin North Am 1253-65, 1985 3. Feins NR: Multiple trauma. Pediatr Clin North Am 26:759771,1979 4. Kuzmarov IW, Morehouse DD, Gibson S: Blunt renal trauma in the pediatric population: A retrospective study. J Urol 126:648649.1981 5. Cass AS: Blunt renal trauma in children. J Trauma 23:123127,1983 6. Cass AS: Renal trauma in multiple-injured child. Urology 21:487-492,1983 7. Spirnak JP: Revascularization of traumatic thrombosis of renal artery. Surg Gynecol Obstet 164:22-26,1987 8. Morse TS, Smith JP, Howard WHR, et al: Kidney injuries in children. J Ural 98:539-547, 1967 9. Karp MP, Jewett TC, Kuhn JP, et al: The impact of computed tomography scanning on the child with renal trauma. J Pediatr Surg 21:617-623,1986 10. Tapper D, Brand T, Hickman R: Early diagnosis and
management of renovascular hypertension. Am J Surg 153:495500.1987 11. Taylor RG, Azmy AF, Young DG: Long-term follow-up of surgical renal hypertension. J Pediatr Surg 22:228-230, 1987 12. Buchi KF, Siegler RL: Hypertension in the first month of life. J Hypertens 4:525-528,1986 13. Brooks WG Jr, Weibley RE: Emergency department presentation of severe hypertension secondary to complications of umbilical artery catheterization. Pediatr Emerg Care 3:104-106, 1987 14. Malin SW, Baumgart S, Rosenberg HK, et al: Non surgical management of obstructive aortic thrombosis complicated by renovascular hypertension in the neonate. J Pediatr 106:630-634. 1985 15. Report of the Second Task Force on Blood Pressure Control in Children-1987. Pediatrics 79:1-25, 1987 16. O’Dea RF, Mirkin BL, Alward CT, et al: Treatment of neonatal hypertension with Captopril. J Pediatr 113:403-406, 1986 17. Shaw NJ, Wilson N, Dickinson DF: Captopril in heart failure secondary to a left to right shunt. Arch Dis Child 63:360363,1988
Hypertension
in a Neonate
By Yehezkel G. Caine, Scott Fields, Hubert Rakotomalala, Yigal Shvil, Shmuel Katz, and Medad Schiller Jerusalem, Israel 0 We report a case of renal trauma followed by hypertension and spontaneous recovery in 8 Z-week-old girl involved in 8 road 8ccident. Copyright
o 1992 by W.B. Saunders Company
INDEX WORDS: Renal trauma, neonatal.
R
ENAL TRAUMA as a result of involvement in accidents is fairly common in children,*‘3 but this apparently does not apply to the neonate. This is probably due to the lack of exposure. CASE REPORT A 2-week-old girl, weighing 3,650 g, was admitted to the emergency room following a road accident in which her parents were seriously injured. (No data are available regarding the mechanism of injury.) On admission she was fully conscious and physical examination was unremarkable. Blood count showed a hemoglobin of 17 g%. She was admitted for observation. During the night of admission, a few drops of blood were found in the vulvar region but no lacerations could be found. Repeat physical examination was negative. About 12 hours later the baby became progressively tachypneic, tachycardic, and red blood cells (RBCs) appeared in the urine, followed by frank hematuria and a drop in hemoglobin initially to 15.2 g%, and in the following hours to 10 g%, necessitating a transfusion of 40 mL of packed cells. Physical examination then showed marked sensitivity in the left upper quadrant of the abdomen and left flank. Biochemistry showed a serum Na 132 mmol/L, glucose 11.5 mmol/L, urea 9.1 mmol/L, alanine aminotransferase 520 IU, alkaline phosphatase 280 IU, and lactate dehydrogenase 3,400 IU. An intravenous pyelogram (IVP) with tomography showed normal right kidney morphology and excretion but no kidney was demonstrated on the left (Fig 1). Ultrasound (US) showed a normal right kidney. The left kidney was markedly enlarged and edematous with a fluid collection around the lower pole (Fig 2). At this point, with obvious left renal damage, an angiogram was considered. Due to the fact that more than 24 hours had passed since the injury, the potential for kidney salvage, if it was a vascular injury (due to a long warm ischemic time as well as very small vessels), was so slight that it didn’t justify the possible complications of angiography in a neonate. Therefore, it was decided to follow her clinically and sonographically. During the following days her condition remained stable. She was active, ate well, and showed no signs of other problems. Repeated US showed no expansion of the hematoma. The hematuria subsided and within a few days the US showed a decrease in the size of the hematoma. On the fifth day her blood pressure started increasing to 95/60 and continued to rise to 125/95 by the 10th day. Repeat IVP was
From the Departments of Pediabic Surgery, Radiology, and Pediatrics, Hadassah University Hospital, Jerusalem, Israel. Address reprint requests to Yehezkel G. Caine, MD, Department of Pedianic Sutge?y, Hadassah University Hospital, Kilyat Hadassah, Ein Karem, PO Box 12000, Jerusalem 91 120, Israel. Copyright o 1992 by W.B. Saunders Company 0022-346819212704~0027$03.0010 520
essentially the same as the original one. Fundus examinations were within normal limits. A DTPA renal scan showed delayed uptake and a smaller image of the left kidney when compared with the right. Because there was no evidence of target organ involvement (ie, electrocardiogram, fundoscopy, chest x-ray, and urinalysis) and no other side effects of the hypertension were found, it was felt that the potential complications and side effects of suitable antihypertensive agents (ie, Captopril), at this stage, outweighed the benefits. A conservative, nonphatmacological approach was selected with close monitoring for signs of deterioration or side effects. Blood pressure was measured frequently with repeated fundus and urine examinations. Renal size was assessed by US. Her blood pressure remained high for about 2 months, fluctuating about values of 100 to 130/70 to 90, yet with no evidence of target organ involvement or side effects. It then began to subside spontaneously, returning by the fourth month to normal values for her age at that point. US at 6 weeks (Fig 3) showed normal-sized kidneys on both sides. An IVP at 4 months (Fig 4) showed normal excretion from both kidneys. Examinations at 6 months and 1 year were completely normal.
DISCUSSION
To the best of our knowledge this is the first reported case of renal trauma in the neonate. Mendez, in his extensive review of renal trauma in 1977,’ refers to a case of an infant (age not given) in whom congenital bilateral ureteropelvic strictures with hydronephrosis became manifest due to anuria following an accident (no details are given in this personal communication by P. Peters). Trauma is the most common cause of death and injury in children aged 1 to 14 years,‘.3 but for obvious reasons trauma, especially road accidents, is very rare in the neonate. Blunt trauma of the kidney is the second most common injury in multiply injured children (after central nervous system injury).1-3 This is attributed to a number of factors that combine to give the child less protection than the adult.4 The management of blunt renal trauma continues to remain controversial in those cases with evidently severe damage to the kidney but an otherwise stable patient. Cass? found that in the more severe renal injuries (laceration, rupture, and vascular pedicle injuries) there was a surgery rate of 17% to 70% with a renal loss rate of 5% to 40%. In neither of his reviews, nor in others,‘.2.4 was there a clear relationship between the surgery rate and the renal salvage rate, with the possible exception of true unilateral pedicle injuries during the first 4 to 12 hours.’ Forty percent to 70% of children with kidney trauma have associated injuries,3*7with up to 33% requiring laparotomies and other surgery for these injuries.’ In the Journal of Pediatric Surgery,
Vol27, No 4 (April), ‘1992: pp 520-522
POSJTRAUMATIC
RENAL-VASCULAR
HYPERTENSION
521
Fig 3. US at 6 weeks showing a normal-sized kidney (bipolar diemeter of 4.5 cm) with complete resolution of the perirenal hematoma and edema.
Fig 1. R/P/CT shortly after admission, showing good uptake in the right kidney but no evidence of uptake in the left.
others for whom there were no other indications for surgery, the indications for exploring the kidney were: deteriorating vital signs, expanding renal mass, septic complications, and persistent significant hematuria.6r7 Diseased and anomalous kidneys are seemingly more prone to trauma,‘x8 with 7% to 17% of the kidneys injured in trauma showing a congenital anomaly.13738 In the present case there was no evidence of concurrent renal disease and her stable clinical condition precluded the need for surgical intervention.
Fig 2. US of the left kidney shortly sfter admission, showing merked enlargement (bipolar diameter of 7 cm), edema, and perirenal hematoms.
Radiological evaluation of the patient has a bearing on the clinical decision. Mostly the evaluation is by IVP with tomography and US.2.9Computed tomography (CT) scans are very useful’ and are becoming more prevalent, although in trauma cases, such as the present are, the recurrent exposure of the neonate to radiation with repeated x-rays, and especially CT scans, can be quite significant and should be considered carefully. Angiography is an important and useful investigation in suspected vascular pedicle damage, but in children, and especially in small infants, it may be very difficult and fraught with complications and should be avoided if possible.* Where available, digital subtraction angiography can be used as a substitute.’ In this case, as noted, we felt that a conservative approach, avoiding potentially dangerous investiga-
Fig 4. tion.
IVP et 4 months showing good bilateral uptake and excre-
CAINE ET AL
522
and surgery, was justified in view of the small chance of kidney salvage with a warm ischemic time of over 24 hours and very small vessels. So as to facilitate serial objective imaging and avoid radiation, US rather than CT was selected for serial follow-up. This showed a nonexpanding hematoma that spontaneously resolved over a period of a few weeks. Coupled with a renal scan showing perfusion of the kidney (at about the time that hypertension set in) we felt that close observation was paying off. Ultimately the kidney recovered completely as shown by the normal IVP and return to normotensive blood pressure. Renovascular hypertension in the neonate has been reported with increasing frequency in the literature. In addition to congenital diseases causing hypertension (eg, coarctation of the aorta, fibromuscular dysplasia, renal artery stenosis),“-” it has been recognized as a complication of umbilical artery catheterization causing renal artery thrombosis.‘0.13.14We have not found any reports of hypertension in the neonate due to renal trauma, but there is no reason to expect a different response to parenchymal damage from that found in older children or adults. The question is one of whether to treat the hypertension, or not, and if so at what stage. The second Task Force on Blood Pressure Control in Children-1987’s proposed a number of guidelines for the initiation of pharmacotherapy. They also raised a number of serious questions and reservations about the use of antihypertensive medication in children in whom nonpharmacological control of the hypertension might be achieved. Their indications for the initiation of antihypertensive drugs
tions
are: (1) significant diastolic hypertension (as defined in their guidelines); (2) evidence of target organ injury; and (3) symptoms or signs related to elevated blood pressure. In this case the blood pressure fell within the range of significant systolic hypertension for the age group, and at times within the severe hypertension group, as did the diastolic pressure. At no time did she show evidence of target organ involvement or other side effects. On the other hand, previous experience’* has shown spontaneous resolution of renovascular hypertension in certain cases. Experience with Captopril (the drug of choice in renovascular hypertension) in neonates has shown that although it is effective in reducing blood pressure, its use has been associated with potentially severe side effects, such as hypotension, renal failure, oliguria, subtle seizures, lethargy, In the balance, therefore, we elected to and apnea. 16.17 wait while closely following her. This with the intention of treating her medically, or performing a nephrectomy, at the first indication further increase in blood pressure or of damage to a target ‘organ. Within a few weeks the blood pressure had leveled off, and decreased rapidly following that. In the light of our experience in this case, as well as that of others,” we feel that the neonate has a reasonable chance for recovery of kidney function, even when severely damaged, with spontaneous resolution of associated hypertension. Medication, in view of its potential for serious side effects in the neonate, should be considered individually and according to the circumstances.
REFERENCES 1. Mendez R: Renal trauma. J Ural 118698703,1977 2. Livne PM, Gonzales ET: Genitourinary trauma in children. Urol Clin North Am 1253-65, 1985 3. Feins NR: Multiple trauma. Pediatr Clin North Am 26:759771,1979 4. Kuzmarov IW, Morehouse DD, Gibson S: Blunt renal trauma in the pediatric population: A retrospective study. J Urol 126:648649.1981 5. Cass AS: Blunt renal trauma in children. J Trauma 23:123127,1983 6. Cass AS: Renal trauma in multiple-injured child. Urology 21:487-492,1983 7. Spirnak JP: Revascularization of traumatic thrombosis of renal artery. Surg Gynecol Obstet 164:22-26,1987 8. Morse TS, Smith JP, Howard WHR, et al: Kidney injuries in children. J Ural 98:539-547, 1967 9. Karp MP, Jewett TC, Kuhn JP, et al: The impact of computed tomography scanning on the child with renal trauma. J Pediatr Surg 21:617-623,1986 10. Tapper D, Brand T, Hickman R: Early diagnosis and
management of renovascular hypertension. Am J Surg 153:495500.1987 11. Taylor RG, Azmy AF, Young DG: Long-term follow-up of surgical renal hypertension. J Pediatr Surg 22:228-230, 1987 12. Buchi KF, Siegler RL: Hypertension in the first month of life. J Hypertens 4:525-528,1986 13. Brooks WG Jr, Weibley RE: Emergency department presentation of severe hypertension secondary to complications of umbilical artery catheterization. Pediatr Emerg Care 3:104-106, 1987 14. Malin SW, Baumgart S, Rosenberg HK, et al: Non surgical management of obstructive aortic thrombosis complicated by renovascular hypertension in the neonate. J Pediatr 106:630-634. 1985 15. Report of the Second Task Force on Blood Pressure Control in Children-1987. Pediatrics 79:1-25, 1987 16. O’Dea RF, Mirkin BL, Alward CT, et al: Treatment of neonatal hypertension with Captopril. J Pediatr 113:403-406, 1986 17. Shaw NJ, Wilson N, Dickinson DF: Captopril in heart failure secondary to a left to right shunt. Arch Dis Child 63:360363,1988
