الفهرس 
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Abstract
Renal trauma account for about 3% of all trauma admissions and 10% of patients who sustain abdominal trauma.the kidney is the most common injured urological organ and most challenging to treat.
Etiology
The following list is not all inclusive,but it highlights the major mechanisms that generate renal trauma.
-penetrating (e.g.gunshot wound,stab wounds).
-blunt(e.g.motor vehicle crash,sports and fall on ground).
-Iatrogenic(e.g.renal biopsy,ESWL,Endo procedures).
-Other(e.g.renal transplant rejection).
Evaluation
An assessment of clinical history ,physical examination, radiological findings, all these help presumptive diagnosis and treatment plan.
A)History:
History of blunt versus penetrating trauma, flank or abdominal pain , rapid deceleration(e.g.,vehicle accident,fall from height) firearm injury, stab wound.
B)Clinical evaluation:
The most important indicators for significant injury are manifestations of shock,Hematuria, hypotension, flank hematoma, abdominal or flank tenderness and penetrating injuries to low thorax or flank.
C)Imaging studies:
1-Ultrasonography:
-non invasive, define anatomy of injury,done in time with resuscitation.
-require an experienced sonographer,bladder injuries may be missed.
2-CT scanning:
-allow functional and anatomical assessment of kidney and urinary tract, the presence or absence of two functioning kidneys, and concurrent injuries.
-patient must be stable, depending on time of contrast and scanning to view bladder and ureters.
3)IVP:
-allow anatomical and functional assessment of both kidneys and ureters, presence of two functioning kidneys, maybe done at emergency or operating room,one shot IVU
-require multiple images, high radiation dose, findings not reveal extent of injury,may give false results.
4)MRI:
-differentiate between old and recent hematoma, used in allergy to contrast materials instead of CT.
-increasing cost and imaging time.
5)ANGIOGRAPHY:
-diagnosis and treatment of renal injuries with suspected vascular injury.
-invasive,require contrast,time consuming.
D)SURGICAL EVALUATION:
In patient who is too unstable, depending on mechanism of injury, lateral retroperitoneal hematoma may refer to renal lacerations.
-STAGING:
American Association for surgery of trauma (ASST) as follow:
Grade1:renal contusion or subcapsular hematoma.
Grade11:renal lacerations confined to cortex <1cm.
Grade111:extendingto medulla>1cm,no extravasation
Grade1V: injury in cortex,medulla,CS,shattered kidney.
GradeV:vascular injury.
MANAGEMENT:
1)conservative:-
The recently released AUA guideline recommends initiation of conservative management in all patients as long as they are hemodynamic ally stable.
GradeV injury and the need for platelet transfusion,which reflect activation of amassive transfusion protocol, have been agood predictors of the need for intervention.
Additionally,normogram have been developed that are able to predict the need for renal exploration with >95% accuracy, one such normogram incorporates acombination ofradiological(injury grade),serological (admission hemoglobin,blood urea nitrogen),and clinically(heart rate,platelet transfusion within 24 h),and is even able to predict the need for renal exploration in the context of aunit that offers embolization as an alternative to surgery.
Grade1V injuries:
Grade IV injuries can be challenging, not only a difficult decision needed to be made between renal exploration and conservative management, but the use and timing of other interventions,e.g., ureteric stenting, percutaneous drainage and embolization, must also be considered.
It must be determined if the patient requires intervention to control bleeding, if they do then embolization preferable to renal exploration if it available and the patient stable enough for this.
In blunt trauma, the anatomic structure of kidney lend itself to conservative treatment,the closed retroperitoneal space around kidney temponade of bleeding renal vessels,kidney rich in tissue factor which activate extrinsic coagulation cascade promoting hemostasis, 85%treated without surgery.
2)Surgical:
-control bleeding,preservation of renal tissue.
-nephrectomy in shattered kidney,uncontrolled bleeding.
-partial nephrectomy in avulsed segment,polar penetrating injury and CS repair.
-adjuncts,absorbable mesh wrap,omentum,topical thrombostatic agents.
-postoperative care :the patient monitored clinically and radiology, hematocritserially.