Abstract
Objective: Grades I to III are the most common kidney injuries, and they are successfully treated non-operatively with high functional preservation. The objective of this study was to review all grade IV renal injuries and report outcomes. It also sought to ascertain whether operative and selective non-operative management could result in high salvage rates and whether management and outcomes varied noticeably between cases of isolated grade IV renal injuries and those with concomitant multi-organ injuries.
Method: The data of 50 grade IV kidney injuries that occurred at Department of Urology, Rajendra Institute of Medical Science, Ranchi for ten years. These were split into two groups: those with isolated grade IV renal injuries (30) and those with accompanying nonrenal injuries (20), and both groups were analyzed with regard to the kind of renal injury, operative vs. nonoperative care, operational nephrectomy rate, and operational renal salvage rate. Salvage was defined as having a 50% or greater function of the injured kidney and an overall renal function of at least 20%.
Results: With an overall salvage rate of 83%, 35 of the 50 patients were operated on and 15 were not. 35 injuries were caused by penetrating trauma, 10 by blunt trauma, and 5 out of 50 (51%) were renal vascular injuries. Grade IV renal injuries requiring operational exploration that also had concurrent related injuries were healed at exploration with a 14% nephrectomy rate and an 82% salvage rate. With an average transfusion need of 8.5 units packed red blood cells, 15 (41%) of the 30 patients with isolated injuries required surgical exploration. One patient (10%) required a nephrectomy, two kidneys were postoperatively nonfunctional, and one mild complication was found. Only 10 patients needed transfusions (average 2.5 units), and 87% of the remaining 20 isolated grade IV renal injuries were handled nonoperatively. There was no need for delayed nephrectomy in any of the 35 nonoperative patients of solitary or nonisolated renal injury. Three individuals had minimal problems, while five cases had non-functioning kidneys.
Conclusion: Since isolated grade IV renal injuries provide a special case where the patient must be treated purely based on the severity of the renal injury, nonoperative therapy is applied more frequently. The primary reason for exploring and reconstructing the kidneys is persistent bleeding. Non-operative therapy should only be used in all cases of severe renal damage when patients are hemodynamically stable and have undergone full renal staging.

Key words: kidney, salvage therapy, wounds and injuries, damage severity score