residents’ room  
Acute Page kidney immediately following blunt trauma to a solitary  
pediatric kidney  
Nicole Tuong; Michael Daugherty, MD; Jonathan Riddell, MD  
SUNY Upstate Medical University, Syracuse, NY, U.S.  
Cite as: Can Urol Assoc J 2016;10(5-6):E192-6.  
Published online May 12, 2016.  
a congenital atrophic right kidney (Fig. 1). On admission,  
his blood pressure was 124/68 mmHg, pulse of 98, and  
a respiration rate of 24. His hemoglobin was 11g/dL and  
hematocrit was 35%.  
Page kidney refers to the occurrence of hypertension secondary to  
renal compression and is usually associated with a subcapsular or  
Hospital admission 1  
perinephric hematoma. It generally occurs weeks to months after  
In the emergency department, the patient received one unit  
the initial injury. We report on a case of Page kidney occurring  
of packed red blood cells (PRBC). A physical exam showed  
acutely after Grade IV blunt renal trauma in a pediatric patient with  
only abdominal tenderness and guarding. A focused assess-  
a solitary kidney following a tobogganing accident. The child was  
ment with sonography for trauma (FAST) exam was negative.  
Repeat hemoglobin and hematocrit were 11g/dL and 33%,  
respectively. He was hospitalized for six days, during which  
his blood pressures ranged from 96134/4388 mmHg. His  
hematocrit decreased to 22.3%, but stabilized at 26% on  
discharge. His renal function and vital signs were stable  
throughout the hospitalization.  
initially managed conservatively and discharged after six days bed-  
rest. He re-presented post-injury Day 12 with recurrent hematuria,  
anemia, hypertension, and renal failure that required eventual, and  
successful, surgical exploration.  
Pediatric renal trauma management guidelines are based  
on the presence of two functioning kidneys and there is a  
paucity of literature describing management of trauma to  
a solitary kidney. Although expectant management is the  
cornerstone of managing most blunt renal trauma, a solitary  
kidney poses different challenges, as there is not a normal  
contralateral unit to provide physiologic compensation — a  
solitary Page kidney being one such example. While mul-  
tiple guidelines state conservative management should be  
tried first in patients with renal trauma, in a pediatric patient  
with a solitary kidney, clinicians should have a low threshold  
for radiologic or surgical management if kidney perfusion  
and renal function start to decline.  
Hospital admission 2  
The patient re-presented to the emergency department six  
days after discharge with with recurrent gross hematuria and  
left upper-quadrant abdominal pain. He did not report any  
additional trauma. His blood pressure was 145/80 mmHg  
with a creatinine of 0.9 mg/dL (increased from a baseline  
creatinine of 0.6 mg/dL), hematocrit of 23.5%, hemoglobin  
8 g/dL, and a white blood cell count (WBC) of 18.9/uL. An  
abdominal ultrasound showed the laceration to the lower  
pole of the left kidney with decreased blood flow and an  
organized hematoma (Fig. 2). There was also a large blood  
clot seen in the patient’s bladder.  
On the next hospital day, his hematocrit dropped to  
0.2%, WBC increased to 21.9/uL, creatinine elevated to  
.7mg/dL, and blood urea nitrogen (BUN) increased to 30  
Case report  
A nine-year-old boy presented to the emergency depart-  
ment approximately eight hours after a tobogganing accident  
with blunt abdominal trauma and dark urine. A computed  
tomography (CT) scan of the abdomen and pelvis with and  
without contrast showed a Grade IV left renal laceration  
with associated left retroperitoneal hematoma, along with  
mg/dL. He was transfused one unit of PRBC. A Doppler  
ultrasound was repeated and showed an increasing large  
heterogeneous, nonvascular collection surrounding his left  
kidney involving the lower pole (Fig. 3). The left renal artery  
had a peak systolic velocity was 135 cm/s at the aorta and  
this increased to 523cm/s at the renal hilum (Figs. 4-5).  
CUAJ • May-June 2016 • Volume 10, Issues 5-6  
2016 Canadian Urological Association  
Pꢀꢁꢂaꢃꢄꢂc ꢄꢀꢅal ꢃꢄauꢆa  
Fig. 1. Outside computed tomography scan of abdomen and pelvis of a Grade  
IV renal laceration with a large retroperitoneal hematoma and an atrophic right  
Fig. 2. Organized perinephric hematoma surrounding the left kidney.  
cular control was achieved by a transmesenteric approach.  
Gerota’s fascia was then opened and noted to be thick and  
contracted in the form of a reactive rind. Upon exposure  
of the left kidney, renal debridement and renorrhapy of the  
lower pole of the left kidney was performed, with five min-  
utes of cross-clamp time. After organized clot evacuation,  
arterial bleeding was found from a lower-pole segmental  
artery supplying a devitalized segment, which was subse-  
quently ligated. An intraoperative renal vascular Doppler  
was performed immediately post-debridement; the inter-  
polar RI was 0.61 and the inferior portion of the interpolar  
RI was 0.47 (Fig. 8). The renal vein demonstrated better  
phasicity, with a peak velocity of 20 cm/s (Fig. 9). In addi-  
tion, the renal artery velocity at the hilum declined to 56  
cm/s (Fig.10).  
At the hilum, there was also reversal of blood flow during  
diastole. Resistive indices (RI) at the interpolar and lower-  
pole arteries of the left kidney measured 1.0 compared to  
the upper pole RI of 0.68 (Fig. 6). In addition, the left renal  
vein showed loss of normal phasicity (Fig. 7).  
As the patient was clinically deteriorating and there was  
concern for permanent renal functional loss, interventional  
radiology vs. surgical exploration was debated by the treat-  
ment team. Angiography with embolization of a bleeding  
segmental vessel +/- perinephric drainage of hematoma  
was considered a viable option, but concerns were that the  
patient would receive a contrast load, the vessel might not  
be acutely bleeding, and the perinephric hematoma might  
be too organized to effectively drain.  
The patient, therefore, underwent an exploratory lapa-  
rotomy. Via upper vertical midline incision, early renovas-  
Fig. 3. Lack of diastolic flow to the lower pole of the left kidney.  
Fig. 4. Increased renal artery velocity at the aorta.  
CUAJ • May-June 2016 • Volume 10, Issues 5-6