Management of a Devascularized Kidney

Initial Assessment and Management

Hemodynamic status is the primary determinant for management approach - unstable patients require immediate intervention while stable patients can be managed non-operatively 2, 1
Diagnostic imaging with IV contrast-enhanced CT with immediate and delayed images should be performed when renal injury is suspected to accurately grade the injury 1
Renal venous pedicle avulsion is the only absolute contraindication for non-operative management (NOM) and angioembolization (AE), requiring immediate surgery 3

Immediate surgical intervention is indicated for uncontrollable life-threatening hemorrhage, avulsion of the renal pedicle with pulsating/expanding retroperitoneal hematoma, and renal vein lesion without self-limiting hemorrhage 1, 2
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be used as a bridge to definitive hemorrhage control in severely unstable patients 1
Nephrectomy is often necessary in these cases, as attempts at revascularization have poor outcomes 4

Non-operative management is the standard of care for hemodynamically stable patients 1, 2
Angiography with super-selective angioembolization is indicated for arterial contrast extravasation, pseudoaneurysms or arteriovenous fistulas, and non-self-limiting gross hematuria 1, 2

Results of kidney artery surgical revascularization are poor, with long-term kidney function preservation rate of less than 25% 2
Percutaneous revascularization with stents has shown better outcomes on renal function than surgical treatment 2
Warm ischemia time longer than 60 minutes leads to significant exponential losses in kidney function 2

In cases of shattered kidney without renal hilum avulsion, angioembolization can be effective 3
For renal artery occlusion, conservative management often leads to severe hypertension requiring subsequent nephrectomy 2
In specialized centers with appropriate expertise, peripheral stent graft placement may be considered for hemostasis while allowing perfusion of the renal artery distal to the injury site 2

Monitor for development of renovascular hypertension with periodic blood pressure monitoring for up to a year 1
Follow-up CT imaging should be performed to monitor for complications 1
In rare instances with uncontrollable hypertension and a functional contralateral kidney, delayed nephrectomy may be necessary 1

Rushing to surgery for a devascularized kidney in a hemodynamically stable patient without other indications for laparotomy 1
Attempting arterial repair in a severely damaged kidney with prolonged warm ischemia time (>240 minutes) 1
Failing to perform follow-up imaging for grade V injuries, which have high complication rates 1
Not monitoring for renovascular hypertension, which can develop as a late complication 1