Renal injuries are not very common, and the number of pediatric kidney injuries is even smaller. One potential complication after this injury is hypertension. As usual, there are many theories as to why this occurs. There are undoubtedly areas of the injured kidney that are under-perfused. The most popular theory is that this results in release of renin, upregulating the renin-angiotensin system. 

But how much do we need to worry about this problem? Retrospective adult studies put the incidence at about 5%, and the onset generally occurs 2 to 8 weeks after injury. 

And what about children? Are they just small adults when it comes to this problem? Primary Children’s Hospital in Salt Lake City designed a retrospective study to try to answer this question. They examined 11 years of their own registry data on children, defined as <18 years old. They focused on high grade injuries (grade III-V), as these should have the highest incidence of complications.

Here are the factoids:

• Hypertension was defined as elevated BP anytime after admission that required control with medication, but only after pain was controlled
• 62 children sustained high grade injury, with an average age of 10
• Most were grade III (21) and grade IV (40)
• Four (6.5%) developed hypertension while hospitalized
• Only two requiring ongoing medication months after discharge
• None of the non-hypertensive children became hypertensive later

Bottom line: Obviously, these numbers are small. The fact that it took over 10 years

at a pediatric hospital to accumulate this data demonstrates the difficulty in getting good, actionable information. It looks like that the incidence is similar to adults (about 5%). It does seem that some patients recover and don’t need long-term medication. I recommend that everyone (adult and child) with a significant renal injury (grade 3+) be monitored for hypertension while in the hospital, and for 2-3 months after discharge by their primary practitioner.

Related posts:

• How to grade renal injury
• Practical tip: how to evaluate hematuria
• Caution: IV contrast and trauma imaging

Reference: The incidence of long-term hypertension in children after high-grade renal trauma. J Ped Surg, in press June 2015.

Many trauma centers insist on reinventing the wheel when it comes to policies and protocols. That’s why I like to share here. It’s so much easier to “borrow” from another center, tweak it until it works for yours, and save lots of time and effort.

Today, I’m sharing our adult “Adult Tranexamic Acid (TXA) in Trauma Patients” policy. The main points are:

• Indications – adult trauma patient with enough blood loss to require transfusion or activation of the massive transfusion protocol
• Timing – Only give if the injury was known to occur within 3 hours, not within 3 hours of arrival in your center
• Dosing – a simple loading dose of 1 gram in 50cc saline give slow push, followed by another gram infused over 8 hours
• Exclusion criteria – Although many are listed, the trauma team will only be able to find out about a few: use of anticoagulants, previous dosing of prothrombin complex concentrate (PCC) or Factor VIIa, and possibly the presence of subarachnoid hemorrhage if a CT has been obtained. If the infusion has already started when one of these criteria is identified, stop the infusion.

Suggestion: To keep your trauma professionals from forgetting this adjunct to resuscitation, consider putting a sign on your massive transfusion protocol coolers that says “Do You Need TXA?” And keep it in the med dispenser near/in your resuscitation rooms so you can get it quickly!

Download the policy here (pdf)

Related posts:

• Rationale for TXA use
  
• Video (5 mins): Use of TXA in community hospitals