The role of nephrectomy in the acutely injured

Hypothesis: The high mortality in patients who undergo nephrectomy after trauma is not secondary to the nephrectomy itself but is the consequence of a more severe constellation of injuries associated with renal injuries that require operative intervention. Design: A retrospective review of all patients identified using International Classification of Diseases, Ninth Revision codes as having sustained renal injuries over a 62-month period. Patients: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Methods: All medical records were reviewed for patient management, definitive care, and outcome. Based on outcome, patients were assigned to either the survivor or non-survivor group. For patients who underwent nephrectomy, intraoperative core temperature changes, estimated blood loss, and operative time were also reviewed. Results: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Twenty-nine patients underwent laparotomy with conservative management of the renal injury, of whom 5 (17.2%) died. Twelve patients had renal injuries repaired and all survived. Thirty-seven patients underwent nephrectomy, of whom 16 (43.2%) died. Compared with nephrectomy survivors, nephrectomy nonsurvivors had a significantly lower initial systolic blood pressure, higher Injury Severity Score, higher incidence of extra-abdominal injuries, shorter operative duration, and higher estimated operative blood loss. The nephrectomy survivors' core temperature increased a mean of 0.5 degreesC in the operating room, while the nephrectomy nonsurvivors' core temperature cooled a mean of 0.8 degreesC. Conclusions: Patients who undergo trauma nephrectomy tend to be severely injured and hemodynamically unstable and warrant nephrectomy as part of the damage control paradigm. That a high percentage of patients die after nephrectomy for trauma demonstrates the severity of the overall constellation of injury and is not a consequence of the nephrectomy itself.