Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imaging. Issue 5 (October 2020)

• Record Type: Journal Article
• Authors: Edwards, Angelena; Hammer, Matthew; Artunduaga, Maddy; Peters, Craig; Jacobs, Micah; Schlomer, Bruce
• Is Part Of: Journal of pediatric urology. Volume 16:Issue 5(2020)
• Page Start: 557.e1
• Page End: 557.e7
• Publication Date: 2020-10
• Subjects: Pediatric -- Renal trauma -- Renal ultrasound -- Diagnostic test study -- Computed tomography -- CT scan -- Hematuria; Pediatric urology -- Periodicals; Urologic Diseases -- Periodicals; Urogenital Diseases -- Periodicals; Urologic Surgical Procedures -- Periodicals; Child; Infant; Urologie pédiatrique -- Périodiques; Appareil urinaire -- Maladies -- Périodiques; Pédiatrie; Urologie; Pediatric urology; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); Electronic journals; Periodicals; Electronic journals; 618.926
• DOI: 10.1016/j.jpurol.2020.04.020
• Languages: English
• ISSNs: 1477-5131

Abstract

Summary: Introduction: The standard imaging modality for hemodynamically stable blunt abdominal trauma patients is a contrast enhanced CT scan, which is reflected in the current AUA urotrauma guidelines. This comes, however, with radiation exposure and the potential sequalae of IV contrast administration in the pediatric patient. Objective: We hypothesize that ultrasound imaging would be able to diagnose and rule out clinically significant renal injuries when compared to the gold standard of CT scan in the setting of pediatric blunt abdominal trauma. Study design: All children <18 years of age who were evaluated for blunt abdominal trauma who had a CT scan and ultrasound imaging of kidneys were identified. The ultrasound images were reviewed by four reviewers who were blinded to CT results and all clinical information. The ability of ultrasound to diagnose and rule out clinically significant renal injury was evaluated by diagnostic test performance characteristics including sensitivity, specificity, negative predictive value and positive predictive value. Results: There were 76 patients identified, 24 of which had a renal injury (1 bilateral) diagnosed by CT scan for a total of 25 injuries in 152 renal units. There were six grade I-II injuries and 19 grade III-V injuries. The sensitivity of the four blinded reviewers by ultrasound alone to detect the 19 grade III-V injuries ranged from 79 to 100% with NPV between 97 and 100%. Three of the four reviewers identified all 19 grade III-V injuries by ultrasound. When combined with significant hematuria, all 19 grade III-IV injuries were identified. Of note, all patients with a grade III-V injury of the kidney had significant hematuria. Of the grade I-II renal injuries, all reviewers identified 1/5 or 2/5 by ultrasound alone. Discussion: The limitations of this study include: its retrospective nature, limited number of patients and reviewers, quality of the ultrasound machine. and experience of technologist, radiologist and urologist. A major limitation is the inability to assess other solid organ injuries during this initial study. Conclusions: When compared to a CT scan as the gold standard, kidney ultrasound images had a sensitivity of 79–100% to detect grade III-V injuries and NPV of 97–100% by four blinded reviewers. All grade III-V injuries had either an episode of gross hematuria or microscopic hematuria >50 RBC/hpf. A prospective study that includes full abdominal imaging is needed to confirm that ultrasound can safely be used in place of CT scan for evaluation of hemodynamically stable blunt trauma patients. Summary Table Patient Characteristics (N = 76) Female 30 (39%) Age in years (median, IQR) 9.4 (6.1–13.5) Number of renal injuries 25 AAST Grade I-II 6 AAST Grade III-V 19 Gross hematuria or >50 RBC/hpf 32 (42%) Diagnostic test performance for ultrasound to diagnose and rule out renal trauma for blinded reviewers All renal trauma Sensitivity NPV Reviewer 1 20/25 (80%) 121/126 (96%) Reviewer 2 20/25 (80%) 125/130 (96%) Reviewer 3 16/25 (64%) 119/127 (93%) Reviewer 4 21/25 (84%) 119/123 (97%) Grade III-V renal trauma Sensitivity NPV Reviewer 1 19/19 (100%) 126/126 (100%) Reviewer 2 19/19 (100%) 130/130 (100%) Reviewer 3 15/19 (79%) 124/128 (97%) Reviewer 4 19/19 (100%) 123/123 (100%) IQR = interquartile range; AAST = American Association for the Surgery of Trauma; RBC = red blood cells; hpf = high power field; NPV = negative predictive value; PPV = positive predictive value; ROC AUC = receiver operating characteristic area under curve