OBJECTIVE To investigate the high nephrectomy rate in patients with gunshot injury at Dicle University Medical School Research Hospital and to determine the factors that affect our nephrectomy decision. METHODS During a 4-year period, 71 patients were hospitalized for renal injuries at our hospital. Renal gunshot injuries (RGIs) were noted in 45 kidneys of 42 patients (59.1%). Twenty-five patients underwent nephrectomy (55.5%). Twenty kidneys were reconstructed (44.4%). The hospital records were reviewed retrospectively. In these two groups of patients, the following clinical data were entered into a computer data base and compared: presence and type of hematuria, type and degree of renal injury, hemodynamic status, results of imaging studies, surgical technique, type of weapon, reason for nephrectomy, associated organ injury, injury severity score, complications, and mortality. RESULTS The patients who underwent renal repair and those who underwent nephrectomy had a mean injury severity score of 33.6 +/- 7.5 and 42.0 +/- 9.9, respectively (P <0.001). The main grade of injury was 4.4 +/-0.8 in nephrectomy patients and 2.8 +/- 0.9 in the patients for whom renal salvage was possible (P <0.05). Patients who required nephrectomy, as a group, appeared to have a higher rate of high-velocity bullet injury (HVBI) (76%) (P <0.05) and higher numbers of associated abdominal injury (P <0.05). CONCLUSIONS HVBI makes extensive tissue debridement imperative and reconstruction difficult. We believe that in RGIs caused by a high-velocity bullet, nephrectomy is more likely to be required. Hemodynamic instability was the major reason for our intraoperative nephrectomy decision. a subcategory of RGI.