Renal injury - Part 2

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I must disagree with those who claim that the presence
(or absence) of the contralateral kidney is irrelevant
in the approach to the injured kidney.  Such claims,
to me, appear to ignore or minimize well-accepted
principles of damage control surgery, principles which
although may not have been corroborated by randomized,
controlled trials, nevertheless seem to hold true in
most clinical scenarios and are accepted as the
standard by many.

My argument is this:  in a truly unstable patient (be
that hemodynamically, thermally or metabolically), the
presence of a normal contralateral kidney (i.e.
palpable and of normal size) obviates the need to
pursue a longer and riskier operation in an attempt to
salvage the damaged kidney, making nephrectomy the
best option for the patient.  The remaining normal
kidney will serve the patient just fine; there is no
need to risk multiple organ failure, sepsis and all
the other complications of prolonged surgery in the
face of deranged homeostatic conditions (i.e. the
Lethal Triangle) in an attempt to perform the best
possible technical operation on the injured kidney. 
It isn’t worth it to the patient; the risk/benefit
ratio is too high

However, if there is NO palpable contralateral kidney,
the result of nephrectomy will be, in 100% of cases,
life-long need for dialysis, with all of its attendant
morbidities, its diminished quality of life, and
shorter patient life span.  In this case, subjecting
the patient to the added risk of prolonged surgery
under hostile conditions (i.e. continuing to operate
despite a dropping temperature, worsening
coagulopathy,  persistent hypotension, or any
combination of these) might be, in some situations, a
justifiable risk.  Obviously if the situation is
clearly one of incipient irreversible shock (i.e. the
patient is already crashing), then the quick
nephrectomy is justified and a life of dialysis is the
only and best alternative to certain death.  But
damage-control situations are “analog” in nature, not
“digital.”  They present a continous possible spectrum
of derangements which are dynamic and progressive. 
Getting the patient out of the operating room BEFORE
the full-blown Lethal Triad is manifest is the goal,
and that’s what makes the whole thing such an art.

Just my opinon.

C.M. Ursic, M.D.
Dept. of Surgery
UCSF-East Bay
Oakland, California


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