The American Association for the Surgery of Trauma renal injury grading scale: Implications of the 2018 revisions for injury reclassification and predicting bleeding interventions

Author(s): Keihani, Sorena; Rogers, Douglas M; Putbrese, Bryn E; Anderson, Ross E; Stoddard, Gregory J; Nirula, Raminder; Luo-Owen, Xian; Mukherjee, Kaushik; Morris, Bradley J; Majercik, Sarah; Piotrowski, Joshua; Dodgion, Christopher M; Schwartz, Ian; Elliott, Sean P; DeSoucy, Erik S; Zakaluzny, Scott; Sherwood, Brenton G; Erickson, Bradley A; Baradaran, Nima; Breyer, Benjamin N; Fick, Cameron N; Smith, Brian P; Okafor, Barbara U; Askari, Reza; Miller, Brandi D; Santucci, Richard A; Carrick, Matthew M; Allen, LaDonna; Norwood, Scott; Hewitt, Timothy; Burks, Frank N; Heilbrun, Marta E; Gross, Joel A; Myers, Jeremy B; in conjunction with the Trauma and Urologic Reconstruction Network of Surgeons | Abstract: BackgroundIn 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions.MethodsData on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared.ResultsOf the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34).ConclusionAbout one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions.Level of evidencePrognostic and Epidemiological Study, level III.