A urology collaborative seeks to standardize care for suspected renal trauma in children. (Stock photo)
Current guidelines for the evaluation and management of renal injury focus on adult patients, as these cases are relatively uncommon among children. In recognition of this gap, Carmen Tong, D.O., alongside a team of experts including David Kitchens, M.D., developed the Trauma Renal Injury Collaborative in Kids (TRICK). Consisting of five Level-1 tertiary pediatric trauma centers across the United States, this initiative aims to standardize both evaluation and management protocols for pediatric patients with high-grade renal trauma.
The importance of studying pediatric renal trauma
Anatomical differences impact children’s susceptibility to renal injury from blunt abdominal trauma. Children’s kidneys are smaller and typically less protected by surrounding anatomical structures, which increases their vulnerability to injury from impact. Children cannot be viewed as “little adults,” but current guidelines for renal trauma typically cater to adult patients, leaving health care providers without clear guidelines for children.
“There are currently no standardized protocols on how to image children with suspected renal trauma. This is partly due to the ‘as low as reasonably achievable’ (ALARA) principle and other efforts to reduce exposure to radiation in this population,” Tong said. “The key is to identify which patients might benefit from any radiation imaging such as CT while avoiding unnecessary repeated imaging in stable, asymptomatic patients.”
Clinicians typically manage renal injury in children with conservative interventions or with repeated imaging for symptomatic patients. “A good number of patients are transferred in from outside institutions with radiographic imaging already obtained,” Kitchens said. “Before our study, we would usually recommend repeating some of these studies as we did not feel they provided necessary information to guide treatment. But now we know that only a small number of these patients (those with gross hematuria or otherwise clinically unstable) will require repeat imaging upon presentation.”
Key findings and implications
At the 2023 Societies for Pediatric Urology meeting in Houston, Tong and Kitchens presented groundbreaking findings from TRICK’s research. One pivotal discovery revealed that children with gross hematuria (visible blood in urine) following trauma benefit from more extensive radiologic evaluation, similar to adult patients. This novel discovery challenges the prevailing assumption that pediatric and adult renal trauma require vastly different diagnostic approaches.
This finding also helps clinicians better recognize pediatric patients at increased risk for surgical intervention who would, by turn, benefit from a more thorough radiographic evaluation. By identifying these children early, healthcare providers can prioritize further radiographic testing. However, for stable, asymptomatic patients, repeat imaging can often be avoided, reducing both patient risk resulting from radiation and overall health care costs.
Advances in diagnosis and treatment
In recent years, the management of pediatric renal trauma has shifted toward conservative approaches, with most injuries resolving without surgical intervention. In many cases, this is thanks to emerging diagnostic tools, such as contrast-enhanced ultrasound. For the 12% of patients requiring surgery in TRICK’s cohort, clinicians used minimally invasive techniques to treat kidney injuries, reflecting advancements in pediatric urology.
Broader implications for trauma care
By collecting data from diverse geographic regions, the TRICK consortium generates robust evidence that single institutions might struggle to achieve independently. This approach not only improves outcomes for pediatric renal trauma but also sets a precedent for addressing other pediatric conditions requiring specialized care.
For parents and guardians, TRICK’s work highlights the importance of vigilance following blunt abdominal trauma. Visible blood in a child’s urine or significant trauma to the side of the body — common in sports injuries or falls — warrants a rapid medical evaluation to rule out renal injury. Educating families about these warning signs promotes early intervention and better outcomes.
The path forward
TRICK’s ongoing efforts aim to standardize imaging protocols, particularly for children with gross hematuria, as a predictor of surgical intervention. Tong predicts that future studies will likely explore additional predictors and refine management strategies, further enhancing pediatric trauma care. Through collaboration and innovation, TRICK continues to make strides in ensuring that children with renal trauma receive the best possible care, tailored to their unique needs.
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