Published online September 1, 2006
PEDIATRICS Vol. 118 No. 3 September 2006, pp. 1019-1027 (doi:10.1542/peds.2006-0663)
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ARTICLE

Single Kidney and Sports Participation: Perception Versus Reality

Matthew M. Grinsell, MD, PhDa, Sharon Showalter, RNa, Katherine A. Gordonb and Victoria F. Norwood, MDa

a Department of Pediatrics, Division of Nephrology
b Curry School of Education, University of Virginia, Charlottesville, Virginia


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: LITERATURE SEARCH...
 REFERENCES
 
OBJECTIVES. Physician opinions and practice patterns regarding the participation of children and adolescents with single, normal kidneys in contact/collision sports are widely varied. We hypothesize that limitation of participation from play based only on the presence of a single kidney is not supported by available data. We sought to determine recommendations of pediatric nephrologists regarding the participation of patients with single, normal kidneys in contact/collision sports and review the literature to determine the rate of sports-related kidney injury compared with other organs.

METHODS. Members of the American Society of Pediatric Nephrology were surveyed regarding their recommendations for participation of patients with single, normal kidneys in contact/collision sports. Medical and sports literature databases were searched to determine sports-related kidney, brain, spinal cord, and cardiac injury rates and the sports associated with kidney injury.

RESULTS. Sixty-two percent of respondents would not allow contact/collision sports participation. Eighty-six percent of respondents barred participation in American football, whereas only 5% barred cycling. Most cited traumatic loss of function as the reason for discouraging participation. The literature search found an incidence of catastrophic sports-related kidney injury of 0.4 per 1 million children per year from all sports. Cycling was the most common cause of sports-related kidney injury causing >3 times the kidney injuries as football. American football alone accounted for 0.9 to 5.3 fatal brain injuries and 4.9 to 7.3 irreversible spinal cord injuries per 1 million players per year. Commotio cordis causes 2.1 to 9.2 deaths per year.

CONCLUSIONS. Most pediatric nephrologists prohibit contact/collision sports participation by athletes with a single kidney, particularly football. The available evidence suggests that cycling is far more likely to cause kidney injury. In addition, kidney injury from sports is much less common than catastrophic brain, spinal cord, or cardiac injury. Restricting participation of patients with a single, normal kidney from contact/collision sports is unwarranted.

Key Words: kidney • sports • wounds and injuries

Abbreviations: AAP—American Academy of Pediatrics • NPTR—National Pediatric Trauma Registry • ASPN—American Society of Pediatric Nephrology • CINAHL—Cumulative Index to Nursing and Allied Health Literature • MVA—motor vehicle accident • MeSH—medical subject heading

Pediatricians are commonly asked to evaluate children and adolescents with single, normal kidneys for participation in contact/collision sports. For the purposes of such evaluations, a single kidney is defined as a morphologically normal kidney without congenital abnormalities that resides in the usual anatomic position. Single kidneys may be slightly larger than paired kidneys but are otherwise entirely normal. Data reporting the incidence of sports-related renal injury have not been readily available to clinical practitioners. As a result, there is controversy within the medical community regarding sports participation recommendations for these patients that balances quality of life and medical concerns.

Before 1994, the American Academy of Pediatrics (AAP) and American Medical Association identified the presence of a single kidney as a disqualifying condition from contact/collision sports.1,2 In addition, the National Kidney Foundation advises kidney donors to avoid contact sports.3 Since 1994, the AAP has recommended a "qualified yes; pending individual assessment" regarding the participation of athletes with single kidneys in contact/collision sports.1 Unfortunately, no clear definition of "individual assessment" is provided by the AAP. No other organizations of medical professionals, including the American Urologic Association, the American College of Sports Medicine, or the American Pediatric Surgery Association, have position statements regarding sports participation by athletes with a single kidney.

Published opinions of medical professionals regarding these patients show little consensus on this issue. Dorsen4 cites varying opinions from sports medicine physicians ranging from complete exclusion to allowing participation if the athlete were exceptionally talented or elite. Sharp et al5 found that 68% of pediatric urologists would recommend that athletes with a single kidney avoid contact sports. Anderson6 found that 46% of members of the American Medical Society for Sports Medicine would counsel athletes and families to avoid full sports participation by athletes with a single kidney. Interestingly, that response increased to 58% if the athlete were their own child. Recently, Johnson et al7 analyzed the National Pediatric Trauma Registry (NPTR) and concluded that current recommendations may be overly protective and need reevaluation. Although the opinions of pediatric urologists and sports medicine practitioners are published, there are no published articles documenting the opinions and practice patterns of pediatricians or pediatric subspecialists regarding the participation of athletes with single kidneys in contact/collision sports.

We hypothesized that the recommendations and opinions of physicians in general and pediatric nephrologists in particular regarding the participation of athletes with single kidneys in contact and collision sports may not be supported by available evidence. We also hypothesized that the rate of kidney injury during contact/collision sports may be lower than that of unpaired organ systems such as brain, spinal cord, and heart.

Our study had 3 objectives: (1) to determine the opinions and recommendations of members of the American Society of Pediatric Nephrology (ASPN) regarding the participation of children and adolescents with single, normal kidneys in contact/collision sports; (2) to review the available literature to determine the rate of sports-related kidney injury; and (3) to put sports-related kidney injury into a context helpful to physicians and families by comparing kidney injury rates to those of brain, spinal cord, and heart in the pediatric population.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: LITERATURE SEARCH...
 REFERENCES
 
Survey of ASPN Members
An e-mail survey was sent to ASPN members inquiring whether they would allow a pediatric patient with a single, normal kidney to participate in contact/collision sports (Fig 1). In addition, they were asked to identify particular sports from which they would preclude participation. The list of potential contact/collision sports presented to the ASPN members was adapted from the AAP.2 Respondents were also asked for their reasons for barring patients with single kidneys from participating in contact/collision sports. Other questions evaluated the recommendation of additional protective equipment and the use of liability waivers. Finally, respondents were surveyed for their personal experiences of patients who had lost kidneys from sports.


Figure 1
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  		FIGURE 1 ASPN member survey.

 
The survey was sent to all of the ASPN members in January 2003 (436 active members including 322 practicing pediatric nephrologists, 78 fellows, and 36 emeritus members). The Human Investigation Committee of the University of Virginia approved this project.

Literature Review: Sports-Related Kidney Injury
PubMed, Ovid Medline, Cumulative Index to Nursing and Allied Health Literature ([CINAHL] published by Ovid), and SPORTDiscus (an international database published by EBSCO Host Research Databases covering sports medicine, exercise physiology, biomechanics, coaching, recreation, and related topics) were searched for articles addressing sports-related kidney injury. All of the searches were performed for English-language articles up to October 2005. Search terms were kept as uniform as possible between databases (Table 1). The Appendix provides detailed descriptions of the strategies used for the literature searches.


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  		TABLE 1 Literature Search Strategies

 
Evaluation of Articles for Review
Articles identified by the literature search results were reviewed by ≥2 of the authors. First, the titles and abstracts were assessed for articles specifically addressing sports-related kidney trauma in children and adolescents. Articles were excluded if they related to nontraumatic kidney impairment, motor vehicle-related injuries, or did not present novel data. Except for Australian Rules football, articles that focused on sports not identified by the AAP were also excluded. In this manner, we identified only those articles that address sports-related kidney injury caused by collision or contact with another player or equipment integral to a given sport, for example, a hockey puck, lacrosse stick, or baseball.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 APPENDIX: LITERATURE SEARCH...
 REFERENCES
 
Objective 1: ASPN Survey
ASPN members returned 135 responses (31%). All of the responses to the survey were kept anonymous.

Sixty-two percent (83 of 135) of respondents would not allow contact/collision sports participation by patients with single, normal kidneys, whereas 34% (46 of 135) would allow participation. Four percent (6 of 135) of responses were indecisive or unclear. Eighty-six percent (72 of 83) of the group who would not allow sports participation identified American football as the primary sport to avoid. Other sports included boxing 75%, ice hockey 70%, rugby 64%, martial arts 60%, and rodeo 54%. Downhill skiing and bicycling were among the activities least likely to be limited by ASPN members (Table 2).


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  		TABLE 2 Sports Discouraged by Pediatric Nephrologists

 
Seventy-three percent (61 of 83) of respondents who would not allow contact/collision sports activity explicitly stated or implied concerns over risk of renal injury and the consequences from subsequent loss of function from sports participation. Thirteen percent (11 of 83) of respondents stated that a single kidney seemed to have an increased risk of injury. Five percent (4 of 83) identified potential medical-legal ramifications from injury-related loss of function as the reason for limiting participation. Five percent (4 of 83) of respondents referred to the AAP Guidelines as justification for limiting participation.

Fifty-four percent (25 of 46) of the nephrologists who would allow participation recommended additional protective equipment. Thirty-seven percent (17 of 46) of this group would have a family sign a waiver indicating that they understood the risks of kidney injury during sports participation.

Among all 135 responses, there were 15 instances of catastrophic renal trauma leading to loss of function from any cause. Twenty percent (3 of 15) of these were sports-related: 1 from diving, 1 from horse jumping, and 1 from American football. The remaining 12 events included a jet-ski accident, 3 motor vehicle accidents (MVAs), and 8 others of unknown etiology. In no case was a solitary kidney injured.

Sports-Related Kidney Injury
The literature search identified 38 sports-related kidney injury articles: 22 retrospective reviews of pediatric renal injury, 4 articles regarding physician attitudes or practice recommendations, and 12 case reports. Table 3 summarizes the results of the 22 retrospective reviews addressing sports-related kidney injury. Seven studies examined kidney injury during participation in a single activity, such as downhill skiing, horseback riding, Australian football, or cycling.8–14 Four of the articles identify sports as a category of kidney injury but do not specify which sports.15–18 Among the remaining 11 articles, which include 5 of the 6 largest patient populations studied, there were a total of 465 sports-related kidney injuries. The most common sports identified were cycling (95 injuries), skiing (91 injuries), soccer (34 injuries), American football (31 injuries), and Australian football (9 injuries).7,19–25 Among all of the articles, American football accounted for 1 nephrectomy.26 However, other sports were responsible for more nephrectomies: 5 from downhill skiing, 4 from cycling, 2 from horseback riding, and 2 from soccer.7,9,10,14,25,27,28 Only 1 article reported an injury to a single kidney: a renal contusion in a high school football player managed conservatively with no long-term complications.19


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  		TABLE 3 Publications of Sports-Related Kidney Injury

 
Only 1 article reported an incidence of sports-related kidney injury in patients with 2 kidneys: 6.9 per 1 million children per year.25 This number is extrapolated from a total population of 290 264 children studied over an 8-year period. When only catastrophic injuries (ie, those resulting in nephrectomy) are considered, the incidence drops to ~0.4 per 1 million children per year.25 That number reflects 1 nephrectomy from a downhill skiing injury over the 8-year observation period. Calculation of the incidence of sports-related kidney injury was not possible from the other articles, because the total population or population at risk were not provided.

In articles that reported all causes of renal injury, MVAs were the most likely cause of serious renal trauma. Depending on the database, MVAs were responsible for 71% to 100% of renal injuries.7,15–21,23,29,30

Twelve case reports documented injuries from 7 sports. American football accounted for 4 kidney injuries; soccer caused 4; and water skiing, downhill skiing, wrestling, jujitsu, and bicycle riding caused 1 each.26–28,31–39 There were 4 nephrectomies identified in the case reports: 2 from soccer and 1 each from American football and downhill skiing.26–28,32 Notably, the nephrectomy because of the football injury was performed for severe hypertension 5 years after the injury. No injuries to solitary kidneys were reported for football.

Injury Patterns of Brain, Heart, and Spinal Cord
Table 4 summarizes the results of the literature search for catastrophic sports-related injury to unpaired organ systems.


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  		TABLE 4 Brain Injury Fatality and Irreversible Spinal Cord and Cardiac Injury Rates

 
Brain Injury
Cantu and Mueller40 reported 497 brain injury-related deaths between 1945 and 1999. Of these fatalities, 374 (75%) were football players participating at the high school level, whereas the remaining deaths occurred during professional, college, and sandlot participation.40 In 1976, new rules prohibiting spearing and face tackling were instituted in an effort to reduce the rate of these injuries. The changes reduced the number of brain injury fatalities from 370 brain injury-related fatalities between 1945 and 1975 (12.3 per year) to 127 from 1975 to 1999 (5.1 per year).40 Using an estimate of 1.0 to 1.5 million high school football players annually in the United States, the incidence of brain injury fatality from 1980 to 1999 is ~0.9 to 3.6 fatalities per 1 million high school players per year.40

Brain injury is the cause of death in the majority of downhill skiing fatalities, accounting for ~50% to 80% of deaths.41 It is estimated that there are 2.5 to 2.9 deaths per 1 million skiers and snowboarders per season, and head injury can, therefore, be estimated to cause 1.2 to 2.3 deaths per 1 million skiers/snowboarders per year.41

Spinal Cord Injury
Cantu and Mueller42 also reported 223 catastrophic (permanent quadriplegia/quadriparesis) spinal cord injuries in American football from 1977 to 2001. Of those, 183 (82%) occurred in high school players. This calculates to an estimated incidence of 4.8 to 7.3 catastrophic spinal cord injuries per 1 million football players per year (Table 4).

Sudden Cardiac Death (Commotio Cordis)
Maron et al43 identified 25 sports-related events of blunt trauma to the chest causing sudden cardiac death in individuals 3 to 19 years old, or ~1.4 deaths from commotio cordis per year. Vincent and McPeak.44 reported an incidence of commotio cordis from high school baseball and softball of 2.1 to 3.3 episodes per year from 1973 to 1990.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 APPENDIX: LITERATURE SEARCH...
 REFERENCES
 
Since 1994, the AAP has recommended a "qualified yes: pending individual assessment" for participation of athletes with single kidneys in contact, collision, and limited contact sports.1 The practice patterns of many physicians responsible for the care of athletes with single kidneys have not followed this recommendation. As shown by our results, pediatric nephrologists, as well as urologists and sports medicine physicians, largely counsel restriction of participation in contact and collision sports for children and adolescents with a solitary kidney.5,6 There were 3 general reasons that pediatric nephrologists gave for limiting participation: the potential for injury to result in end-stage renal disease or death, increased risk of injury because of the normal hypertrophy of single kidneys, and concern over medicolegal action in the case of renal injury. None of these arguments seems to be upheld by the evidence. Although the loss of a solitary kidney would indeed be catastrophic, we have been unable to document that the risk of that event is noteworthy. Indeed, the risk of loss of life from injuries to other organs is significantly more likely. In response to the second concern, if the presence of a single kidney actually increased the risk of injury, it would be expected that athletes with single kidneys would be overrepresented in the trauma literature. Based on the estimate of single kidney incidence of 1:1500,5,6 there should be ~33 patients with single kidneys in the NPTR review by Johnson et al,7 ~55 patients in the NPTR review by Wan et al,21 and another 10 patients with a single kidney in the review by McAleer et al.24 However, none of these articles reported an injury to a solitary kidney. Among all of the articles found by our literature review, only 10 single kidneys were mentioned. Only 1 patient with a single kidney experienced a sports-related renal injury: a mild renal contusion while playing American football.19 The remaining 9 single kidneys were found incidentally during evaluations for non–sports-related trauma and were not injured. To the third argument, the concern of medicolegal consequences is certainly controversial, and a full discussion is outside the scope of this article. However, it should be noted that some athletes have used the legal system to successfully argue that prohibiting sports participation is discriminatory.7,45,46

ASPN members most commonly recommend avoidance of American football to reduce the risk of kidney injury. Boxing was second, although the AAP does not endorse participation in boxing for anyone.2 Contrary to these recommendations, our literature search results demonstrated that downhill skiing, cycling, and horseback riding account for more catastrophic renal injuries than American football but were limited by ≤20% of ASPN members. Indeed, cycling was the activity least likely to be limited, with only 5% of ASPN members identifying cycling as a sport to avoid. The observation that cycling, downhill skiing, and horseback riding are responsible for more catastrophic kidney injuries is consistent with the previous analysis of the NPTR data by Johnson et al.7

As noted by other authors, direct statistical analysis and calculation of absolute risk is often difficult or impossible because of the retrospective nature of the studies and unknown or unreported total numbers of participants.25 In particular, the calculated incidences of sports-related brain and spinal cord injury are based on an estimated number of participants and not the total population at risk. However, to put sports-related kidney injury into a helpful context for practitioners, we compared the estimated sports-related injury to kidneys to other unpaired organs based on the best available data. The incidence of catastrophic sports-related kidney injury is ~0.4 per 1 million children per year.25 This is significantly lower than the estimated incidence of spinal cord and brain injury from football or skiing/snowboarding (ranging from 0.9 to 15.8 injuries per 1 million per year; Table 4). In all of the articles reviewed for sports-related kidney injury, fewer nephrectomies occurred on a yearly basis than episodes of commotio cordis. Based on the available data, the likelihood of sustaining catastrophic sports-related injury to unpaired organ systems is highest for spinal cord, then brain, followed distantly by heart and kidney.

Recently, Johnson et al7 reviewed the NPTR, concluded that the current AAP recommendations may be overprotective, and suggested reevaluation. Based on our evidence, we agree that limitation of patients with single kidneys from collision/contact sports is unwarranted. There is no doubt that loss of function of a single kidney would be devastating to an individual and would necessitate dialysis and transplantation. However, quadriplegia/quadriparesis because of spinal cord injury, loss of life from traumatic brain injury, or cardiac arrest are also devastating events that apparently occur more frequently than kidney injury within the pediatric population, and no limitation on participation is currently considered based on these potential outcomes. We believe that the outcomes of sports participation, particularly physical fitness, socialization, and teamwork, outweigh the minimal risk of renal injury. At the very least, families can be reassured that renal injury risk should not be the driving force in deciding about contact/collision sports activities for children and adolescents.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
APPENDIX: LITERATURE SEARCH...
 REFERENCES
 
The majority of pediatric nephrologists discourage contact/collision sports participation by athletes with single kidneys. In particular, avoidance of American football is counseled. However, a review of the available data shows that cycling and skiing are ~3 times more likely to cause renal injury and catastrophic loss of function. In addition, catastrophic injuries to brain, spinal cord, or heart are much more common than renal injury. We believe that the current practice patterns of physicians and the recommendations of the AAP would benefit from reevaluation, modification, and clarification to help families make reasonable choices for their children.


   APPENDIX: LITERATURE SEARCH STRATEGIES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: LITERATURE SEARCH...
REFERENCES
 
Sports-Related Kidney Injury
The databases below were searched for English-language publications regarding sports-related kidney injury, and search terms were kept as uniform as possible between databases. The strategy for evaluation of articles is presented at the end of this section. In the search strategies, medical subject headings (MeSHs) and keyword subject headings are identified.

PubMed Search
PubMed (1966 to October 2005) was searched using keywords "kidney," "sports," and "injuries." This search identified 91 publications, 24 of which were fully reviewed.

A keyword search with "single kidney" and "sports" identified 14 publications, 3 of which were fully reviewed.

A keyword search with "single kidney" and "injuries" yielded 274 articles, 2 of which were fully reviewed.

A keyword search for "solitary kidney" and "sports" yielded 7 publications, all of which met criteria for full review.

A keyword search for "solitary kidney" and "injuries" found 61 articles, 10 of which were fully reviewed.

Ovid Medline Search
Ovid Medline (1966 to October 2005) was searched for sports-related kidney injuries. When possible, any MeSH that resulted from a search term was used. Otherwise, a keyword search for the topic of interest was performed. A keyword search for "single kidney" yielded no corresponding MeSHs and resulted in 370 publications. The keyword "injury" resulted in the MeSH "wounds and injuries." All of the subheadings were included, resulting in 308 987 publications. Another keyword search for "sports" also resulted in a MeSH for "sports" with 45 856 publications. Combining the searches for keyword "single kidney" and MeSHs "wounds and injuries" and "sports" yielded no publications.

A combined keyword search for "single kidney" and "sports" also found no publications.

A combined keyword search for "single kidney" and MeSH "wounds and injuries" found 10 articles, 2 of which met the criteria below for full review.

A keyword search for "solitary kidney" resulted in 625 publications without a corresponding MeSH. Combining these results with those for MeSHs "wounds and injuries" and "sports" found 2 publications, which were reviewed.

A combined search for keywords "solitary kidney" and "sports" identified 3 articles, which were fully reviewed.

A combined keyword search for "solitary kidney" and MeSH "wounds and injuries" identified 13 articles, 7 of which were fully reviewed.

A keyword search for "kidney" resulted in a MeSH for "kidney" with 188 930 publications. Combining the MeSH "kidney" with "wounds and injuries" and "sports" yielded 34 publications, 15 of which were fully reviewed.

SPORTDiscus Search
SPORTDiscus is an international database published by EBSCO Host Research Databases covering sports medicine, exercise physiology, biomechanics, coaching, recreation, and related topics. SPORTDiscus (1975 to October 2005) was searched with keywords "kidney," "injury," and "sports." This search yielded 36 publications, of which 9 were fully reviewed.

CINAHL Search
CINAHL was searched from 1982 to October 2005. A search for the MeSH "kidney" yielded 958 articles. A search for the MeSH "sports" resulted in 11 961 articles. Combining the 2 search results identified 14 articles, 4 of which were fully reviewed.

Unpaired Organ Systems
To compare the risk of sports-related kidney injury with injuries of vital unpaired organ systems, PubMed was searched for articles describing catastrophic sports-related injuries to brain, spinal cord, and heart.

Brain Injury Fatality
PubMed (1966 to October 2005) was searched using keywords "brain," "sports," and "death," which resulted in 81 publications. These articles were reviewed for large, seminal articles providing data on our age group of interest. Three articles were selected that represent large, pediatric populations with sports-related injuries.

Irreversible Spinal Cord Injury
PubMed (1966 to October 2005) was searched using keywords "spinal cord," "injury," and "sports," which resulted in 703 articles. These articles were also reviewed for large, seminal articles providing data on our age group of interest. Two articles were selected that adequately represented the pediatric population at risk for sports-related spinal cord injury.

Commotio Cordis
Commotio cordis is a nonpenetrating chest injury that causes ventricular fibrillation and death. PubMed (1966 to October 2005) was searched using keywords "commotio cordis" and "sports," which yielded 32 articles. Two articles were selected that provided data on commotio cordis and sports participation.


   ACKNOWLEDGMENTS
 
This work was supported by National Institutes of Health training grant 5T32HL07956-03.

We recognize Matthew J. Gurka, PhD, and Kelly K. Gurka, MPH, for advice on comparisons of injury rates. We also recognize Lisa Workman, MS, Amy Mangrum, MD, Laura Blanchard, MD, and Jonathan Swanson, MD, for helpful comments and review of this article.


   FOOTNOTES
 
Accepted Apr 10, 2006.

Address correspondence to Matthew M. Grinsell, MD, PhD, University of Virginia, Department of Pediatrics, Division of Nephrology, 1224 Jefferson Park Ave, Suite 701, Charlottesville, VA 22903. E-mail: mmg4x{at}virginia.edu

Dr Grinsell has had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 DISCUSSION
 CONCLUSIONS
 APPENDIX: LITERATURE SEARCH...
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R. H. Brophy, S. C. Gamradt, R. P. Barnes, J. W. Powell, J. J. DelPizzo, S. A. Rodeo, and R. F. Warren
Kidney Injuries in Professional American Football: Implications for Management of an Athlete With 1 Functioning Kidney
Am. J. Sports Med., January 1, 2008; 36(1): 85 - 90.
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