The Acute Kidney Injury Network (AKIN) Criteria Applied in Burns:

Decoding burn trauma: biomarkers for early diagnosis of burn-induced pathologies

Burn injuries represent a significant global challenge due to their multifaceted nature, characterized by a complex cascade of metabolic and immune dysfunction that can result in severe complications. If not identified and managed promptly, these complications can escalate, often leading to fatal outcomes. This underscores the critical importance of timely and precise diagnosis. Fortunately, biomarkers for burn-induced pathologies and outcomes have emerged as powerful diagnostic and prognostic tools. These biomarkers enable early diagnosis and intervention, facilitate risk assessment, support patient-specific treatment, monitoring of disease progression, and therapeutic efficacy, ultimately contributing to improved patient outcomes. However, while previous studies have provided valuable biomarkers for the detection of burn-induced pathologies, many of these were constrained by the techniques and sample sizes available at the time, which can limit the generalizability of the findings. This review highlights numerous biomarkers studied in the literature to date, underscoring the need to replicate these findings in more diverse and representative populations. It also emphasizes the importance of advancing research efforts to develop more efficient, accurate, and cost-effective approaches for integrating biomarkers into clinical practice.

Factors influencing vancomycin trough concentration in burn patients: a single center retrospective study

Objective

To analyze factors influencing the vancomycin trough concentration in burn patients to provide a basis for the more rational use of vancomycin in these patients.

Materials and methods

We collected the clinical data of adult burn patients treated with vancomycin in a Chinese hospital. Vancomycin was administered at a dosing regimen of 1.0 g q12 h. Patients were divided into a therapeutic group with vancomycin trough concentration in the target therapeutic range (10-20 μg/mL) and a subtherapeutic group with vancomycin trough concentration in the subtherapeutic range (<10 μg/mL).

Results

The therapeutic group included 14 patients (17.5%), with an average trough concentration of 14.36 ± 2.82 μg/mL; the subtherapeutic group included 66 patients (82.5%), with an average trough concentration of 5.18 ± 2.77 μg/mL. The serum creatinine level was significantly higher in the therapeutic group (84.93 ± 47.26 μmol/L) than that in the subtherapeutic group (62.44 ± 14.49 μmol/L) (p < 0.01). Serum albumin levels were significantly lower in the therapeutic group (30.50 ± 2.28 g/L) than those in the subtherapeutic group (34.00 ± 6.22 g/L) (p < 0.05). Using receiver operating characteristic (ROC) curve analysis, for serum albumin, the area under the ROC curve (AUC) (95% confidence interval [CI]) was 0.67 (0.553, 0.788); the optimal cut-off point was 34.50 g/L (p = 0.046), the sensitivity was 0.379, and the specificity was 1.0. For creatinine clearance, the AUC (95% CI) was 0.72 (0.537, 0.902); the optimal cut-off point was 76.64 mL/min (p = 0.01), the sensitivity was 0.985, and the specificity was 0.5. The linear stepwise regression equation was as follows: trough concentration = 0.14 × age + 0.071 × serum creatinine -4.196.

Conclusion

In this study, a high proportion of burn patients had a vancomycin trough concentration below the standard range. Serum creatinine clearance and albumin levels are important indicators for predicting whether the vancomycin trough concentration is within the standard range. Using a linear stepwise regression equation, the vancomycin trough concentration can be estimated using the patient's age and serum creatinine level.

Long-term renal function after burn-related acute kidney injury with continuous renal replacement therapy

Acute kidney injury (AKI) is a common complication of severe burn injury and is associated with significant morbidity and mortality. Continuous Renal Replacement Therapy (CRRT) is the preferred treatment for stage 3 AKI due to severe burn. This retrospective cohort study at a single institution aimed to examine the long-term renal outcomes after discharge of burn survivors who underwent CRRT during their ICU stay between 2012-2021 due to burn-related AKI, hypothesizing a return to baseline renal function in the long term. Among the 31 patients meeting inclusion criteria, 22 survived their burn injuries, resulting in a 29 % mortality rate. No significant disparities were observed in demographics, comorbidities, burn characteristics, or critical care interventions between survivors and non-survivors. Serum creatinine and eGFR values normalized for 91 % of patients at discharge. Impressively, 91 % of survivors demonstrated a return to baseline renal function during long-term (>3 years) follow-up. Furthermore, only 18 % underwent dialysis after discharge, primarily within the first year. Cumulative mortality rates were 18.2 %, 22.7 %, and 31.8 % at 1, 3, and > 3 years after discharge, respectively. Causes of death were primarily non-renal. These results suggest that burn-related AKI with CRRT results in lower rates of conversion to ongoing renal dysfunction compared to general ICU cohorts. Despite limitations, this study contributes vital insights into the underexplored issue of long-term outcomes after dicharge in this patient population.

Extracorporeal Organ Support for Burn-Injured Patients

As mortality relating to severe acute burn injury improves, patients are surviving longer into the critical care phase, which is commonly complicated by multisystem organ failure. Extracorporeal organ support (ECOS) represents a set of potential therapeutic technologies for managing patients with organ-specific complications. This article provides a comprehensive review of the existing literature, focusing on the use of continuous kidney replacement therapy, extracorporeal membrane oxygenation, extracorporeal carbon dioxide removal, and extracorporeal blood purification. Though promising, many of these technologies are in the early phases of implementation and are restricted to well-resourced medical systems, limiting their use in large scale casualty and austere scenarios.

Pioneering predictions of AKI and AKIN severity in burn patients: a comprehensive CBC approach

This study aims to evaluate the utility of complete blood count (CBC) markers, in conjunction with the acute kidney injury network (AKIN) criteria, for the early detection, severity assessment, and prediction of mortality outcomes of acute kidney injury (AKI) in burn patients. The research seeks to fill existing gaps in knowledge and validate the cost-effectiveness of using CBC as a routine diagnostic tool for better management of AKI. The study was conducted at Hangang Sacred Heart Hospital. We performed a large-scale retrospective analysis of 2758 adult patients admitted to the burn intensive care unit over a 12-year period. Among these patients, AKI occurred in 1554 patients (56.3%). Based on the AKIN stage classification, 794 patients (28.8%) were categorized as AKIN 1, 494 patients (17.9%) as AKIN 2, and 266 patients (9.6%) as AKIN 3. We defined several ratio markers, including the Neutrophil-to-lymphocyte ratio (NLR), Platelet-to-lymphocyte ratio (PLR), Monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), and various mean platelet volume (MPV) ratios. Our statistical analyses, conducted using the R programming language, revealed significant correlations between these markers and AKI severity. The AUC values for neutrophil count and WBC count were 0.790 and 0.793, respectively, followed by immature granulocyte count with an AUC of 0.727. For red blood cell (RBC)-related parameters, the AUC values for hematocrit (Hct), hemoglobin (Hb), and RBC count were 0.725, 0.713, and 0.713, respectively. Among the platelet-related parameters, only platelet distribution width (PDW) had an AUC of 0.677. Among the ratio markers, the NLR had the highest AUC at 0.772, followed by MPVNR and SII with AUC values of 0.700 and 0.680, respectively. The findings underscore the potential of CBC as an economical, routine test for AKI, thereby paving the way for enhanced patient outcomes. Our study suggests the utility of routine CBC tests, specifically WBC count and PLR, for predicting AKI and platelet, MPV, and NLR for mortality assessment in burn patients. These findings underscore the potential of easily accessible CBC tests in enhancing AKI management. However, further multicenter studies are needed for validation.

Early acute kidney injury is associated with in-hospital adverse outcomes in critically ill burn patients: an observational study

BACKGROUND

There are no studies in large series of burn patients on the relationship between acute kidney injury (AKI) and adverse outcomes using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

METHODS

We retrospectively analysed data from a cohort of burn patients admitted to the intensive care unit (ICU) with the diagnosis of burn injury. The diagnosis of AKI over the first 7 days after injury was made according to the KDIGO guidelines. The primary outcome was ICU mortality. We used estimative models using univariable and multivariable logistic regression analyses.

RESULTS

A total of 960 patients were studied and AKI was diagnosed in 50.5%. In multivariable analysis, AKI was associated, as compared with patients without AKI, with ICU mortality {adjusted odds ratio [aOR] 2.135 [95% confidence interval (CI) 1.384-3.293]} and secondary outcomes [kidney replacement therapy, aOR 4.030 (95% CI 1.838-8.835); infection, aOR 1.437 (95% CI 1.107-1.866); hospital mortality, aOR 1.652 (95% CI 1.139-2.697)]. AKI stage 1 was associated with a higher ICU [aOR 1.869 (95% CI 1.183-2.954)] and hospital mortality [aOR 1.552 (95% CI 1.050-2.296)] and infection [aOR 1.383 (95% CI 1.049-1.823)]. AKI meeting the urine output (UO) criterion alone was not associated with increased mortality. Ignoring the UO criterion would have missed 50 (10.3%) cases with AKI.

CONCLUSION

The KDIGO guidelines are useful to diagnose AKI in burn patients. Even the mild form of AKI is independently associated with increased mortality. Considering the UO criterion is important to more accurately assess the incidence of AKI, but AKI meeting the UO criterion alone is not associated with increased mortality.

Critical Care of the Burn Patient

Care of the critically ill burned patient must integrate a multidisciplinary care team composed of burn care specialists. As resuscitative mortality decreases more patients are surviving to experience multisystem organ failure relating to complications of their injuries. Clinicians must be aware of physiologic changes following burn injury and the implicated impacts on management strategy. Promoting wound closure and rehabilitation should be the backdrop for which management decisions are made.

Accuracy of SCORTEN in predicting mortality in toxic epidermal necrolysis

BACKGROUND

Toxic epidermal necrolysis (TEN) patients require multi-directional and multi-disciplinary treatment. In most cases, they are hospitalised at intensive care units and require multi-directional, burn-complication preventive care. Choosing the most appropriate treatment option might be troublesome even when predicting scores are used. SCORTEN is the most renowned prognostic score for TEN patients, however, there are some data indicating that the accuracy of this test may be limited. The credibility of not just the predicted mortality risk, but also componential laboratory results and clinical features subject to debate. The aim of this study was to evaluate the efficacy and credibility of SCORTEN in clinical practice, on proprietary material.

METHODS

A retrospective analysis of 35 patients with diagnosed in histopathology TEN was performed. The inclusion criteria were as follows: day of submission before 5th day from the onset of the symptoms, full protocol of plasmaphereses and IVIGs according to our scheme. Our protocol includes cycle of plasmapheresis with frozen fresh plasma twice daily for the first 2 days following admission, and once daily for the subsequent 5 to 7 days. IVIGs were administered after the first two sessions of plasmapheresis, for 4 to 7 days. The dosage was calculated according to body weight, at 0.4 to 0.5 g/kg per dose.

RESULTS

The sensitivity of SCORTEN for the analysed cohort was 100%, with a specificity of 24%. The estimated death was 41,9%, while the actual death rates were 12,5%. Our protocol improved the survival, OR = 26,57, RR = 6,34, p = 0,022. Decrease in mortality was caused by a combined treatment protocol we use- plasmaphereses with IVIGs. No independent risk factor was significant in death evaluation.

CONCLUSION

Our data suggest that the scoring system for predicting death among TEN patients are reliable when they are high. New prognostic factors should be found to improve the evaluation of patients with low SCORTEN.

Renal replacement therapy for acute kidney injury in burn patients, an international survey and a qualitative review of current controversies

BACKGROUND OF THE STUDY

Acute kidney injury (AKI) is a common complication in critically ill burn patients and is associated with a number of serious adverse outcomes. The clinical decision-making process related to the management of AKI in burn patients is complex and has not been sufficiently standardized. The main aim of this study was to explore the diagnostic approach and clinician's attitudes toward the management of AKI and RRT in burn patients around the world.

METHODS

The questionnaire was widely distributed among the members of International Society for Burn Injury (ISBI), who were invited to complete the survey. Data collection and report was compliant with the the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) Web-survey guidelines. The survey form with multiple-choice questions was divided into 3 parts: a. physician and institutional demographics, b. AKI diagnostic information, c. technical aspects of RRT.

RESULTS

A total of 44 respondents worldwide submitted valuable data in the 2-month period. Of all respondents, 43.2% were from Europe, 30% from North America, 7% from South-East Asia 2.3% from Africa and 18.2% from other regions. 93.1% of participants declare that they use specific definitions to detect AKI, while 11.4% declare the use of renal ultrasonography for AKI diagnosis. CRRT appeared to be the most preferred option by 43.2% of participants, followed by intermittent hemodialysis (25%), and prolonged intermittent RRT (6.8%). The expertise to deliver a modality and the availability of resources were considered important factors when selecting the optimal RRT modality by 20.5% and 29.6% of respondents. The use of specific serum biomarkers for AKI diagnosis are stated by 16% of respondents; 25% of specialists refer to the use of biomarkers of AKI as a criterium for discontinuing the RRT. Femoral vena and right jugular vena were the most frequently used location for RRT temporary catheter placement, 54.6% of respondents declared using ultrasound guidance for catheter placement.

CONCLUSIONS

The majority of burn specialists use specific consensus classifications to detect acute kidney injury. Continuous renal replacement therapy appeared to be the most preferred option, while the expertise to deliver a particular modality and resources availability play a significant role in modality selection. The use of ultrasound and specific biomarkers for AKI evaluation is infrequent in routine clinical practice.

Hypoxia-Inducible Factors and Burn-Associated Acute Kidney Injury-A New Paradigm?

O₂ deprivation induces stress in living cells linked to free-radical accumulation and oxidative stress (OS) development. Hypoxia is established when the overall oxygen pressure is less than 40 mmHg in cells or tissues. However, tissues and cells have different degrees of hypoxia. Hypoxia or low O₂ tension may be present in both physiological (during embryonic development) and pathological circumstances (ischemia, wound healing, and cancer). Meanwhile, the kidneys are major energy-consuming organs, being second only to the heart, with an increased mitochondrial content and O₂ consumption. Furthermore, hypoxia-inducible factors (HIFs) are the key players that orchestrate the mammalian response to hypoxia. HIFs adapt cells to low oxygen concentrations by regulating transcriptional programs involved in erythropoiesis, angiogenesis, and metabolism. On the other hand, one of the life-threatening complications of severe burns is acute kidney injury (AKI). The dreaded functional consequence of AKI is an acute decline in renal function. Taking all these aspects into consideration, the aim of this review is to describe the role and underline the importance of HIFs in the development of AKI in patients with severe burns, because kidney hypoxia is constant in the presence of severe burns, and HIFs are major players in the adaptative response of all tissues to hypoxia.

Admission creatinine is associated with poor outcomes in burn patients

INTRODUCTION

Renal failure is the most common organ failure in severely burned patients. However, defining acute kidney injury and renal failure is very challenging. This study was designed to determine the relationship between a biomarker commonly measured on admission, serum creatinine, and outcomes in burn patients.

METHODS

We conducted a retrospective cohort study of adult patients (≥ 18 years) with a burn ≥ 5% total body surface area (TBSA) and a serum creatinine level measured within the first 72 h after injury. Patients were admitted over an 11-year period and divided into two groups based on creatinine levels measured within the first 72 h after injury. Patients were categorized in the high creatinine group if they had a measured creatinine ≥107 μmol/L (≥1.21 mg/dL); this value was chosen as the threshold for creatinine based on our institution's reference range. Clinical outcomes included morbidities, hospital length of stay, and mortality. Multivariable logistic regression was used to model the association between high admission creatinine and each outcome, adjusting for patient and injury characteristics.

RESULTS

We studied 923 patients, mean age 47 ± 18 years and median 13% (IQR 8-24) TBSA burned. There were 718 patients categorized with low admission creatinine and 205 patients with high admission creatinine. After adjustment for patient and injury characteristics, high admission creatinine was associated with a significantly higher rate of sepsis (OR 3.44; 95% CI 2.11-5.59), pneumonia (OR 4.56; 95% CI 1.8-11.53), and mortality (OR 3.59; 95% CI 1.91-6.75).

CONCLUSIONS

Elevated creatinine on admission is associated with an increased risk of morbidity and mortality. We suggest that admission creatinine can be used as a "red flag" to identify patients at a higher risk for poor outcomes.

A model for acute kidney injury in severe burn patients

INTRODUCTION

In patients with severe burns, morbidity and mortality are high. One factor related to poor prognosis is acute kidney injury. According to the AKIN criteria, acute kidney injury has 3 stages based on urine output, serum creatinine level, and renal replacement therapy. In this study, we aimed to create a decision tree for estimating risk of acute kidney injury in patients with severe burn injuries.

METHODS

We retrospectively evaluated 437 adult patients with ≥20% total burn surface area injury who were treated at the Baskent University Ankara and Konya Burn Centers from January 2000 to March 2020. Patients who had high-voltage burn and previous history of kidney disease were excluded. Patient demographics, medical history, mechanism of injury, presence of inhalation injury, depth of burn, laboratory values, presence of oliguria, need for renal replacement therapy, central venous pressure, and prognosis were evaluated. These data were used in a "decision tree method" to create the Baskent University model to estimate risk of acute kidney injury in severe burn patients.

RESULTS

Our model provided an accuracy of 71.09% for risk estimation. Of 172 patients, 78 (45%) had different degrees of acute kidney injury, with 26 of these (15.1%) receiving renal replacement therapy. Our model showed that total burn surface area was the most important factor for estimation of acute kidney injury occurrence. Other important factors included serum creatinine value, burn injury severity score, hemoglobin value, neutrophil-to-lymphocyte ratio, and platelet count.

CONCLUSION

The Baskent University model for acute kidney injury may be helpful to determine risk of acute kidney injury in burn patients. This determination would allow appropriate treatment to be given to high-risk patients in the early period, reducing the incidence of acute kidney injury.

Early Acute Kidney Injury Following Major Burns

Acute kidney injury (AKI) early after a major burn has not been widely studied. Our purpose was to evaluate the prevalence of and risk factors for early AKI and the effect of early AKI on outcome. Retrospective cohort study of adults with burns ≥20% TBSA admitted between November 24, 2015 and July 1, 2019. "Early AKI" occurring within 7 days of injury was identified using urine output and serum creatinine Kidney Disease International Global Outcome criteria. Multivariate regression models were developed for development of early AKI, development of AKI on day 0 or 1 postburn ("very early AKI"), and for in-hospital death. Among 85 patients, 62.4% developed early AKI, of which 26% had stage 3 AKI. Renal replacement therapy was required in 64% of stage 3 patients by day 7. Patients with early AKI were significantly older [50 (40.5-61) vs 37.5 (27.2-46.8) years, P < .001], and a significantly greater proportion was intubated in the first 24 hours postburn (90.6 vs 59.4%, P = .001). Resuscitation with high-dose vitamin C (HDVC) was independently associated with more frequent early AKI. Older age was significantly associated and HDVC was closely associated with increased very early AKI. In-hospital mortality was 37.7% for patients with early AKI. Older age, larger burn size, and development of early stage 3 AKI were independently associated with increased in-hospital death. Early AKI is common and carries a poor prognosis for survival. Resuscitation involving HDVC appears to be related to a higher likelihood of early and possibly very early AKI.

Physiology of Human Hemorrhage and Compensation

Hemorrhage is a leading cause of death following traumatic injuries in the United States. Much of the previous work in assessing the physiology and pathophysiology underlying blood loss has focused on descriptive measures of hemodynamic responses such as blood pressure, cardiac output, stroke volume, heart rate, and vascular resistance as indicators of changes in organ perfusion. More recent work has shifted the focus toward understanding mechanisms of compensation for reduced systemic delivery and cellular utilization of oxygen as a more comprehensive approach to understanding the complex physiologic changes that occur following and during blood loss. In this article, we begin with applying dimensional analysis for comparison of animal models, and progress to descriptions of various physiological consequences of hemorrhage. We then introduce the complementary side of compensation by detailing the complexity and integration of various compensatory mechanisms that are activated from the initiation of hemorrhage and serve to maintain adequate vital organ perfusion and hemodynamic stability in the scenario of reduced systemic delivery of oxygen until the onset of hemodynamic decompensation. New data are introduced that challenge legacy concepts related to mechanisms that underlie baroreflex functions and provide novel insights into the measurement of the integrated response of compensation to central hypovolemia known as the compensatory reserve. The impact of demographic and environmental factors on tolerance to hemorrhage is also reviewed. Finally, we describe how understanding the physiology of compensation can be translated to applications for early assessment of the clinical status and accurate triage of hypovolemic and hypotensive patients. © 2021 American Physiological Society. Compr Physiol 11:1531-1574, 2021.

Long-Term Outcome After Renal Replacement Therapy in Severe Burns

Acute kidney injury is a common sequela after major burn injury, but only a small proportion of patients need renal replacement therapy. In the majority of patients, need for renal replacement therapy subsides before discharge from the burn center but limited literature exists on long-term outcomes. A few studies report an increased risk for chronic renal failure after burn injury. We investigated the long-term outcome of severely burned patients receiving renal replacement therapy during acute burn injury treatment. Data on 68 severely burned patients who received renal replacement therapy in Helsinki Burn Centre between November 1988 and December 2015 were collected retrospectively. Thirty-two patients survived and remained for follow-up after the primary hospital stay until December 31, 2016. About 56.3% of discharged patients were alive at the end of follow-up. In 81.3% of discharged patients, need for renal replacement therapy subsided before discharge. Two patients received renal replacement therapy for longer than 3 months; however, need for renal replacement therapy subsided in both patients. One patient required dialysis several years later on after the need for renal replacement therapy had subsided. This study showed that long-term need for renal replacement therapy is rare after severe burn injury. In the vast majority of patients, need for renal replacement therapy subsided before discharge from primary care. Acute kidney injury in association with burns is a potential but small risk factor for later worsening of kidney function in fragile individuals.

Preoperative Vitamin D Concentration and Cardiac, Renal, and Infectious Morbidity after Noncardiac Surgery

BACKGROUND

Low 25-hydroxyvitamin D is associated with cardiovascular, renal, and infectious risks. Postsurgical patients are susceptible to similar complications, but whether vitamin D deficiency contributes to postoperative complications remains unclear. We tested whether low preoperative vitamin D is associated with cardiovascular events within 30 days after noncardiac surgery.

METHODS

We evaluated a subset of patients enrolled in the biobank substudy of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were at least 45 yr with at least an overnight hospitalization. Blood was collected preoperatively, and 25-hydroxyvitamin D was measured in stored samples. The primary outcome was the composite of cardiovascular events (death, myocardial injury, nonfatal cardiac arrest, stroke, congestive heart failure) within 30 postoperative days. Secondary outcomes were kidney injury and infectious complications.

RESULTS

A total of 3,851 participants were eligible for analysis. Preoperative 25-hydroxyvitamin D concentration was 70 ± 30 nmol/l, and 62% of patients were vitamin D deficient. Overall, 26 (0.7%) patients died, 41 (1.1%) had congestive heart failure or nonfatal cardiac arrest, 540 (14%) had myocardial injury, and 15 (0.4%) had strokes. Preoperative vitamin D concentration was not associated with the primary outcome (average relative effect odds ratio [95% CI]: 0.93 [0.85, 1.01] per 10 nmol/l increase in preoperative vitamin D, P = 0.095). However, it was associated with postoperative infection (average relative effect odds ratio [95% CI]: 0.94 [0.90, 0.98] per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.005) and kidney function (estimated mean change in postoperative estimated glomerular filtration rate [95% CI]: 0.29 [0.11, 0.48] ml min 1.73 m per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.004).

CONCLUSIONS

Preoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomes. However, there was a significant association between vitamin D deficiency and a composite of infectious complications and decreased kidney function. While renal effects were not clinically meaningful, the effect of vitamin D supplementation on infectious complications requires further study.

Assessing the NephroCheck® Test System in Predicting the Risk of Death or Dialysis in Burn Patients

Acute kidney injury (AKI) is associated with high mortality in burn patients. Urinary biomarkers can aid in the prediction of AKI and its consequences, such as death and the need for renal replacement therapy (RRT). The purpose of this study was to investigate a novel methodology for detecting urinary biomarkers, the NephroCheck® Test System, and assess its ability to predict death or the need for RRT in burn patients. Burn patients admitted to the United States Army Institute of Surgical Research (USAISR) burn intensive care unit were prospectively enrolled between March 2016 and April 2018. A urine sample was obtained from all study participants using the NephroCheck® system. Patient and injury characteristics were gathered, and descriptive statistics were calculated and multivariable logistic regression analyses were performed using these data. Of the 69 patients in this study, 15 patients (21.7%) attained the composite outcome of death or needing RRT within 30 days of urine collection. NephroCheck® scores were higher for patients with the composite outcome, with P = 0.06 for centrifuged scores and P = 0.04 for noncentrifuged scores. Centrifuged and noncentrifuged scores were in high agreement and correlation (R2 = 0.97, P < 0.0001). Noncentrifuged scores were significant in the unadjusted analysis, but they were not significant in the adjusted analysis. Although these scores had a lower sensitivity and negative predictive value compared with other parameters, they had the second highest specificity and positive predictive value. NephroCheck® scores were higher in burn patients with the composite outcome of death or needing RRT, and they demonstrated comparable sensitivity and specificity to creatinine and TBSA.

Acute Kidney Injury After Burn: A Cohort Study From the Parkland Burn Intensive Care Unit

Acute kidney injury (AKI) is a common and morbid complication in patients with severe burn. The reported incidence of AKI and mortality in this population varies widely due to inconsistent and changing definitions. They aimed to examine the incidence, severity, and hospital mortality of patients with AKI after burn using consensus criteria. This is a retrospective cohort study of adults with thermal injury admitted to the Parkland burn intensive care unit (ICU) from 2008 to 2015. One thousand forty adult patients with burn were admitted to the burn ICU. AKI was defined by KDIGO serum creatinine criteria. Primary outcome includes hospital death and secondary outcome includes length of mechanical ventilation, ICU, and hospital stay. All available serum creatinine measurements were used to determine the occurrence of AKI during the hospitalization. All relevant clinical data were collected. The median total body surface area (TBSA) of burn was 16% (IQR: 6%-29%). AKI occurred in 601 patients (58%; AKI stage 1, 60%; stage 2, 19.8%; stage 3, 10.5%; and stage 3 requiring renal replacement therapy [3-RRT], 9.7%). Patients with AKI had larger TBSA burn (median 20.5% vs 11.0%; P < .001) and more mechanical ventilation and hospitalization days than patients without AKI. The hospital death rate was higher in those with AKI vs those without AKI (19.7% vs 3.9%; P < .001) and increased by each AKI severity stage (P trend < .001). AKI severity was independently associated with hospital mortality in the small burn group (for TBSA ≤ 10%: stage 1 adjusted OR 9.3; 95% CI, 2.6-33.0; stage 2-3 OR, 35.0; 95% CI, 9.0-136.8; stage 3-RRT OR, 30.7; 95% CI, 4.2-226.4) and medium burn group (TBSA 10%-40%: stage 2-3 OR, 6.5; 95% CI, 1.9-22.1; stage 3-RRT OR, 35.1; 95% CI, 8.2-150.3). AKI was not independently associated with hospital death in the large burn group (TBSA > 40%). Urine output data were unavailable. AKI occurs frequently in patients after burn. Presence of and increasing severity of AKI are associated with increased hospital mortality. AKI appears to be independently and strongly associated with mortality in patients with TBSA ≤ 40%. Further investigation to develop risk-stratification tools tailoring this susceptible population is direly needed.

Acute kidney injury in burn patients admitted to the intensive care unit: a systematic review and meta-analysis

Background

Acute kidney injury (AKI) is a common complication in burn patients admitted to the intensive care unit (ICU) associated with increased morbidity and mortality. Our primary aim was to review incidence, risk factors, and outcomes of AKI in burn patients admitted to the ICU. Secondary aims were to review the use of renal replacement therapy (RRT) and impact on health care costs.

Methods

We conducted a systematic search in PubMed, UpToDate, and NICE through 3 December 2018. All reviews in Cochrane Database of Systematic Reviews except protocols were added to the PubMed search. We searched for studies on AKI according to Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE); Acute Kidney Injury Network (AKIN); and/or Kidney Disease: Improving Global Outcomes (KDIGO) criteria in burn patients admitted to the ICU. We collected data on AKI incidence, risk factors, use of RRT, renal recovery, length of stay (LOS), mortality, and health care costs.

Results

We included 33 observational studies comprising 8200 patients. Overall study quality, scored according to the Newcastle-Ottawa scale, was moderate. Random effect model meta-analysis revealed that the incidence of AKI among burn patients in the ICU was 38 (30–46) %. Patients with AKI were almost evenly distributed in the mild, moderate, and severe AKI subgroups. RRT was used in 12 (8–16) % of all patients. Risk factors for AKI were high age, chronic hypertension, diabetes mellitus, high Total Body Surface Area percent burnt, high Abbreviated Burn Severity Index score, inhalation injury, rhabdomyolysis, surgery, high Acute Physiology and Chronic Health Evaluation II score, high Sequential Organ Failure Assessment score, sepsis, and mechanical ventilation. AKI patients had 8.6 (4.0–13.2) days longer ICU LOS and higher mortality than non-AKI patients, OR 11.3 (7.3–17.4). Few studies reported renal recovery, and no study reported health care costs.

Conclusions

AKI occurred in 38% of burn patients admitted to the ICU, and 12% of all patients received RRT. Presence of AKI was associated with increased LOS and mortality.

Trial registration

PROSPERO (CRD42017060420)

Improved outcomes of renal injury following burn trauma

BACKGROUND

Acute kidney injury (AKI) is common in major burn injuries and associated with increased mortality. With advances in surgical and critical care it is unclear if mortality in this population remains this high. This study aims to describe incidence and outcomes of patients admitted to intensive care (ICU) with a burn injury who develop AKI. We additionally sought to determine risk factors for developing AKI.

METHODS

A historical cohort study of patients admitted to ICU from 2010 to 2016 with major burn injury was conducted. Demographic, laboratory, and clinical information was collected. AKI was defined by Acute Kidney Injury Network (AKIN) classification. Multivariable logistic regression was used to model association between baseline risk factors and risk of AKI.

RESULTS

Of the 151 patients included, 64 people developed AKI (42%) defined by stages 1-3 of AKIN criteria. The median TBSA was 20% (IQR 9-41). Renal replacement therapy was required in 18/64 (28%) who developed AKI. Multivariable logistic regression demonstrated association between AKI and the following variables: APACHE II score (OR 1.2, 95%CI 1.1-1.3, P = 0.001), age (OR 1.8 per 10-year increase, 95%CI: 1.2-2.5, P = 0.002) and log(TBSA). Fractional polynomial regression analysis demonstrates that the best functional form of TBSA was in the natural logarithm (OR 2.7, 95%CI: 1.5-4.7, p = 0.001). Compared to those without AKI, patients with AKI had longer duration of mechanical ventilation, (median 11 [IQR 6-19] vs. 4 [IQR 2-9] days), ICU stay (15 [IQR 9-22] vs. 6 [IQR 3-10] days), and increased mortality (14 of 64(22%) vs. 4 of 87(5%).

CONCLUSIONS

AKI is common in patients with a major burn injury. However, mortality is lower than described in the literature, particularly for those who required renal replacement therapy.

Predictive Biomarkers for Acute Kidney Injury in Burn Patients

Acute kidney injury (AKI) is an independent and complicated risk factor in burn patients, which cause high mortality and morbidity rate. Diagnosing the biomarkers and early detection of AKI may be helpful in treatment and control the stability of these patients. In this study, we aim to identify predictive biomarkers in order to prevent AKI incidence and sudden death in burn victims. In this retrospective study, 258 burn patients who were admitted to burn center in Shiraz, Iran were evaluated during January 2016 to February 2018. Demographic characteristics, biochemical biomarkers, length of hospital stay, and mortality information were obtained from patient registries program and evaluated the biomarkers in identifying AKI patients into early and late groups. Receiver operating characteristic curve, area under the curve (AUC), univariate, and multivariate logistic regression analysis were used to diagnose the performance of biomarkers in order to predict the AKI. Of 258 patients, 40 (15.50%) were detected as AKI, with estimated mortality rate of 76.9%. Among all the variables, total BSA (P = .01), blood urea nitrogen (BUN; P = .001), potassium (P = .02), and mortality (P = .03) were significantly different in AKI developing. Moreover, AUC of serum creatinin, albumin, and BUN as predictive biomarkers were 0.73, 0.44, and 0.707, respectively. Among all variables, BUN marker was independently associated with AKI developing. Following burn shock, AKI is a common complication that causes increasing mortality and morbidity. Early diagnosis and identifying the biomarkers is preventing sudden death in burn patients and develop appropriate treatments in these victims.

Risk factors and outcome of acute kidney injury in elderly trauma patients

BACKGROUND

Acute Kidney Injury (AKI) is associated with significant morbidity. The risk factors for AKI in elderly trauma patients have not been defined.

METHODS

Injured patients 75 years old or older from 2014 to 2016 were evaluated. AKI was identified by RIFLE criteria. Patients with and without AKI were compared with chi square, ANOVA, and logistic regression.

RESULTS

836 patients were 75 years old or older. Patients with AKI were more commonly male, hypotensive on admission with a greater Injury Severity Score but age, diabetes, hypertension and baseline creatinine were similar. Patients with AKI had a higher mortality that did not increase with RIFLE stage. Male sex, ISS, hypotension on admission and presence of an extremity injury were independently associated with AKI by logistic regression.

CONCLUSION

AKI in elderly trauma patients is associated with magnitude of injury and shock but not pre-existing medical comorbidities and it significantly increased the risk of death.

Acute kidney injury after burn surgery: Preoperative neutrophil/lymphocyte ratio as a predictive factor

BACKGROUND

Severe inflammation and acute kidney injury (AKI) are serious adverse events after burn injuries. The neutrophil/lymphocyte ratio (NLR) is a marker of inflammation. We evaluated the independent risk factors for postoperative AKI, including NLR, in burn-injured patients.

METHODS

The preoperative, intraoperative, and postoperative variables of 473 burn-injured patients were collected. The risk factors for AKI after burn surgery were evaluated using univariate and multivariate logistic regression analyses. The receiver operating characteristic (ROC) curve analysis of preoperative NLR was performed. The 3-month mortality after surgery was also compared between AKI and non-AKI groups using Kaplan-Meier analysis with a log-rank test.

RESULTS

Postoperative AKI occurred in 71 of 473 (15.0%) burn patients. The total body surface area burned (odds ratio (OR), 1.013; 95% confidence interval (CI), 1.001-1.026; P = 0.037), inhalation injury (OR, 1.821; 95% CI, 1.008-3.292; P = 0.047), and preoperative NLR (OR, 1.094; 95% CI, 1.064-1.125; P < 0.001) were risk factors for AKI after surgery. The area under the ROC curve was 0.767, with an optimal cut-off value of 11.7. Moreover, the 3-month mortality after surgery was significantly higher in the AKI group than in the non-AKI group (49.3% vs 14.9%, P < 0.001).

CONCLUSION

Total body surface area burned, inhalation injury, and preoperative NLR are risk factors for AKI after burn surgery, which is associated with early postoperative mortality. Preoperative NLR can provide useful information for the early detection of postoperative AKI and subsequent mortality in burn-injured patients.

Validation of RIFLE, AKIN, and a modified AKIN definition ("backward classification") of acute kidney injury in a general ICU: Analysis of a 1-year period

The aim of this study was to validate Acute Kidney Injury Network (AKIN) and to develop a modified AKIN aimed at an improved classification of patients without baseline creatinine versus Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE) in general intensive care unit (ICU) patients.We retrospectively analyzed medical records of general ICU patients over a 1-year period. We compared the grading of severity as well as the prediction of mortality and renal replacement therapy by AKIN and RIFLE. Furthermore, a modified AKIN score was evaluated.A total of 321 patients were included. In 87% of cases, the 2 definitions classified patients in the concordant severity group. Higher scores of AKIN and RIFLE were associated with increased ICU- and 28-day mortality. Both definitions provided large receiver operating characteristics (ROC)-area under the curve (AUCs) for the prediction of mortality, which were comparable to the ROC-AUC of unclassified serum creatinine. Modification of the AKIN score with a "backward classification" of baseline creatinine based on its time course resulted in a higher AKIN score in 32 patients.RIFLE and AKIN definitions had a high concordance in staging the severity of acute kidney injury. There was a strong relationship between the stages and need for dialysis, ICU, and 28-day mortality. However, unclassified serum creatinine values were at least comparable. Standardized observation of the creatinine time course allows for "ex-post" AKIN-classification in a substantial number of patients with missing baseline creatinine values.

Risk Factors for Acute Kidney Injury in Patients With Burn Injury: A Meta-Analysis and Systematic Review

Acute kidney injury (AKI) is a fatal complication of burn injury. Few systematic reviews to date have focused on the risk factors predisposing to AKI in patients with burn injury. The aim of this article is to identify the risk factors for the occurrence of AKI in burn patients, thus providing theoretical evidence for prevention and treatment. We performed a systematic review and meta-analysis of studies determining the prevalence, risk factors, and outcomes of AKI in patients with burn injury. An electronic search (up to April 2016) was performed using Pubmed, Embase, Web of Knowledge, and the Cochrane Library databases. Finally, a total of 18 articles (nine prospective cohort, seven retrospective cohort, two case-control) meeting the eligibility criteria were included. The pooled incidence of AKI was 39.6% (95% confidence interval = 34.7-44.4%). Significant risk factors for the occurrence of AKI included age (odds ratio [OR] = 3.78 [1.28-6.27]), TBSA (OR = 15.66 [11.01-20.31]), full-thickness TBSA (OR = 15.66 [11.01-20.31]), flame burn (OR = 1.56 [1.09-2.25]), inhalation injury (OR = 2.97 [1.80-4.89]), abbreviated burn severity index on admission (OR = 2.42 [1.87-2.98]), sequential organ failure assessment score on admission (OR = 2.69 [1.39-3.98]), baseline blood urea nitrogen (OR = 2.11 [0.72-3.51]), serum creatinine (OR = 2.69 [1.39-3.98]), and sepsis (OR = 4.42 [1.75-11.18]). In addition, burn patients with AKI are more likely to have long stay in intensive care unit and high mortality. AKI is a common complication and occurs at a remarkable rate in burn patients. We identified 10 variables as independent risk factors for the development of AKI in burn patients. Our findings may help clinicians to develop effective preventive and therapeutic strategies and provide appropriate, timely initial treatment.

Burns: Pathophysiology of Systemic Complications and Current Management

As a result of many years of research, the intricate cellular mechanisms of burn injury are slowly becoming clear. Yet, knowledge of these cellular mechanisms and a multitude of resulting studies have often failed to translate into improved clinical treatment for burn injuries. Perhaps the most valuable information to date is the years of clinical experience and observations in the management and treatment of patients, which has contributed to a gradual improvement in reported outcomes of mortality. This review provides a discussion of the cellular mechanisms and pathways involved in burn injury, resultant systemic effects on organ systems, current management and treatment, and potential therapies that we may see implemented in the future.

Acute Kidney Injury: It's not just the 'big' burns

BACKGROUND

Acute Kidney Injury (AKI) complicates the management of at least 25% of patients with severe burns and is associated with long term complications. Most research focuses on the patients with more severe burns, and whether the same factors are associated with the development of AKI in patients with burns between 10 and 19% total body surface area (TBSA) is unknown. The aims of this study were to examine the incidence of, and factors associated with, the development of AKI in patients with %TBSA≥10, as well as the relationship with hospital metrics such as length of stay (LOS).

METHODS

Retrospective medical record review of consecutive burns patients admitted to The Alfred Hospital, the major adult burns centre in Victoria, Australia. Demographic and injury details were recorded. Factors associated with AKI were determined using multiple logistic regression.

RESULTS

Between 2010 and June 2014, 300 patients were admitted with burn injury and data on 267 patients was available for analysis. Median age was 54.5 years with 78% being male. Median %TBSA was 15 (IQR 12, 20). The AKI incidence, as measured by the RIFLE criteria, was 22.5%, including 15% (27/184) in patients with %TBSA 10-19. Factors associated with AKI included increasing age and %TBSA (OR 1.05 p<0.001) as well as increased surgeries (p<0.041) and a cardiac comorbidity (p<0.01). All patients with renal comorbidity developed AKI. In the %TBSA 10-19 cohort, only increasing age (OR 1.05 p<0.001) was associated with AKI. After accounting for confounding factors, the probability of discharge from hospital in Non-AKI group was greater than for the AKI patients at all time points (P<0.001).

CONCLUSION

This is the first study to show an association between patients with %TBSA 10-19 and AKI. Given the association between AKI and complications, prospective research is needed to further understand AKI in burns with the aim of risk reduction.

Characterization of variables for potential impact on vancomycin pharmacokinetics in thermal or inhalation injury

OBJECTIVE

To characterize the pharmacokinetics of vancomycin dosing in thermal or inhalation injury as they relate to percent total body surface area burn (TBSA) and days since injury (DSI).

METHODS

This retrospective 3-year study included patients with thermal or inhalation injury receiving vancomycin. Patient demographics and course data were collected using the institution's electronic medical record.

RESULTS

Six hundred and fifty-four patients were included in the study; 124 remained after exclusion. Clearance (CL) was augmented in patients closer to their date of injury. CL and total daily dose requirements significantly increased with larger percent TBSA injured that was independent of volume of distribution (Vd). Larger percent TBSA also predicted increased occurrence of renal injury prior to vancomycin initiation. A modified sample set was also analyzed to control for renal dysfunction. Creatinine clearance (CrCl) estimated via the Cockcroft-Gault equation significantly impacted CL and total daily dose. To obtain a goal trough of 15-20mg/L, the average patient in the modified sample with ≥10% TBSA required 64.7mg/kg/day (or 16.2mg/kg every 6hours).

CONCLUSIONS

DSI, percent TBSA, and CrCl can be used to predict faster vancomycin CL and need for higher total daily doses. Augmented pharmacokinetics can occur as early as two days after injury and decrease with time. Acceptable target trough attainment is still lacking and this data should assist in performance improvements for initial vancomycin dosing.

Presenting hypertension, burn injury, and mortality in combat casualties

INTRODUCTION

The effect of presenting hypertension is poorly studied in combat casualties. We hypothesized that elevated mean arterial pressure (MAP) on presentation to combat hospitals would be associated with poor outcomes.

METHODS

Data was obtained from the Department of Defense Trauma Registry and the Armed Forces Medical Examiner System. Variables analyzed included presenting vital signs to Role II-III military theater hospital, demographic variables, injury severity score (ISS), location and mechanism of injury, presence of traumatic brain injury (TBI), acute kidney injury (AKI), and mortality. Patients were stratified by decile of MAP and logistic regression analysis was employed to adjust for confounders.

RESULTS

A total of 4072 subjects injured from February 2002 to February 2011 were identified. Compared to patients in the middle deciles of presenting MAP, patients in the highest and lowest MAP deciles were the only groups that demonstrated a higher mortality on univariate analysis (OR 2.06, 95% CI 1.16-2.31 and OR 2.86, 95% CI 1.76-4.67, respectively), and this relationship persisted after adjustment for ISS, HR, temperature, presence of burn injury, TBI, and AKI. Burn injury was associated with mortality in the full multivariate analysis. However, further analysis limited to patients without burn injury did not demonstrate an association between high MAP and mortality (OR 0.84, 95% CI 0.36-1.99; p=0.70). Conversely, when limited to patients with burn injury, high MAP was associated with mortality (OR 3.78, 95% CI 1.74-8.20; p=0.001).

CONCLUSION

The relationship between mortality and presenting MAP appears to be U-shaped, demonstrating increased mortality in the lowest and highest deciles. However, mortality in the highest MAP decile appears to be limited to casualties with associated burn injury, even after adjustment for TBI, AKI, and ISS, which takes into account the severity of the burn injury. Physicians should recognize that burn patients presenting with an elevated MAP are at an increased risk for poor outcomes.

LEVEL OF EVIDENCE

III.

Reciprocal Risk of Acute Kidney Injury and Acute Respiratory Distress Syndrome in Critically Ill Burn Patients

OBJECTIVE

To evaluate the association between acute respiratory distress syndrome and acute kidney injury with respect to their contributions to mortality in critically ill patients.

DESIGN

Retrospective analysis of consecutive adult burn patients requiring mechanical ventilation.

SETTING

A 16-bed burn ICU at tertiary military teaching hospital.

PATIENTS

Adult patients more than 18 years old requiring mechanical ventilation during their initial admission to our burn ICU from January 1, 2003, to December 31, 2011.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total 830 patients were included, of whom 48.2% had acute kidney injury (n = 400). These patients had a 73% increased risk of developing acute respiratory distress syndrome after controlling for age, gender, total body surface area burned, and inhalation injury (hazard ratio, 1.73; 95% CI, 1.18-2.54; p = 0.005). In a reciprocal multivariate analysis, acute respiratory distress syndrome (n = 299; 36%) demonstrated a strong trend toward developing acute kidney injury (hazard ratio, 1.39; 95% CI, 0.99-1.95; p = 0.05). There was a 24% overall in-hospital mortality (n = 198). After adjusting for the aforementioned confounders, both acute kidney injury (hazard ratio, 3.73; 95% CI, 2.39-5.82; p < 0.001) and acute respiratory distress syndrome (hazard ratio, 2.16; 95% CI, 1.58-2.94; p < 0.001) significantly contributed to mortality. Age, total body surface area burned, and inhalation injury were also significantly associated with increased mortality.

CONCLUSIONS

Acute kidney injury increases the risk of acute respiratory distress syndrome in mechanically ventilated burn patients, whereas acute respiratory distress syndrome similarly demonstrates a strong trend toward the development of acute kidney injury. Acute kidney injury and acute respiratory distress syndrome are both independent risks for subsequent death. Future research should look at this interplay for possible early interventions.

Hypertension after injury among burned combat veterans: A retrospective cohort study

BACKGROUND

The long-term health effects of burn are poorly understood. We sought to evaluate the relationship between burn and the subsequent development of hypertension.

METHODS

Retrospective cohort study of patients admitted to our burn center from 2003 to 2010. Data collected included demographic variables, burn size, injury severity score, presence of inhalation injury, serum creatinine, need for renal replacement therapy, as well as days spent in the hospital, in the intensive care unit and on mechanical ventilation. Data for the subsequent diagnosis of hypertension was obtained from medical records. Cox proportional hazard regression models were performed to determine what factors were associated with hypertension.

RESULTS

Of the 711 patients identified, 670 were included for analysis after exclusions. After adjustment, only age (HR 1.06 per one year increase, 95% confidence interval 1.03-1.08; p<0.001), percentage of total body surface area burned (HR 1.11 per 5% increase, 95% confidence interval 1.04-1.19; p=0.002) and acute kidney injury (HR 1.68, 95% confidence interval 1.05-2.69; p=0.03) were associated with hypertension.

CONCLUSION

Burn size is independently associated with the subsequent risk of hypertension in combat casualties. Clinical support for primary prevention techniques to reduce the incidence of hypertension specific to burn patients may be warranted.

Early and Late Acute Kidney Injury in Severely Burned Patients

Background

This study evaluated factors influencing early and late occurrence of AKI in severely burned patients and assessed the relationship between time of occurrence of AKI and mortality of AKI patients.

Material/Methods

Renal function was evaluated at 3 time points: at admission, at the critical point or middle point of hospitalization, and at the endpoint for which death or a discharge from the center was considered. AKI criteria were: decrease in GFR of less than 60 ml/min at admission, decrease in GFR of more than 75% compared to baseline, and decrease in the daily diuresis of less than 500 ml/24 h.

Results

At admission, 15.1% of the patients had eGFR <60 ml/min. AKI occurred in 38.5% of cases. The occurrence of AKI was associated with: elderly age (p<0.001), female sex (p=0.017), overweight and obesity (p=0.055); extent and depth of burns, respiratory failure, low protein concentration (for all p<0.001), low blood pressure (p=0.014), and high WBC (p=0.010). Early AKI was detected in 28% of patients. Mortality was 100% with the initial GFR ≥60, 100% with the initial GFR <60 and early deterioration of renal function, 80% with the initial GFR <60 and late worsening, and 60% with the initial GFR <60 and no worsening. Late AKI was observed in 10% of patients and mortality in this group was 79.2%. Mortality in the entire group with AKI was 88.0% versus 24.5%.

Conclusions

The frequent occurrence of AKI, especially early, worsens the prognosis for survival. Assessment of renal function should be included in the prognostic scales for burned patients.

Acute Kidney Injury in Critically Injured Combat Veterans: A Retrospective Cohort Study

BACKGROUND

Acute kidney injury (AKI) has been associated with mortality after traumatic injury. However, there is a paucity of data for military service members with injuries received in combat. We sought to identify risk factors for AKI after combat trauma and evaluate whether AKI is a predictor of mortality.

STUDY DESIGN

Retrospective observational study.

SETTINGS & PARTICIPANTS

US service members who were critically wounded in Iraq or Afghanistan from February 1, 2002, to February 1, 2011, and survived until evacuation to Landstuhl Regional Medical Center, Germany.

PREDICTORS

Demographic variables, vital signs, injury severity score, presence of burn injury, and mechanism of injury as defined at the time of initial injury, as well as the presence of AKI ascertained within the first 7 days using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine criteria.

OUTCOMES

Logistic regression models were used to identify risk factors for both AKI and death.

RESULTS

Of 6,011 records, 3,807 were included for analysis after excluding patients with missing data. AKI occurred in 474 (12.5%) patients and 112 (2.9%) died. More patients with versus without AKI died (n=62 [13.1%] vs n=50 [1.5%]; P<0.001). After adjustment, AKI was a predictor of mortality (OR, 5.14; 95% CI, 3.33-7.93; P<0.001). Predictors of AKI were age, African American race, injury severity score, amputations, burns, and presenting vital signs.

LIMITATIONS

AKI diagnoses limited to creatinine-based definitions.

CONCLUSIONS

AKI predicted mortality in combat veterans injured in the wars in Iraq and Afghanistan.

Update on Severe Burn Management for the Intensivist

Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.

Effects of hydrogen-rich saline on early acute kidney injury in severely burned rats by suppressing oxidative stress induced apoptosis and inflammation

Background

Early acute kidney injury (AKI) in severely burned patients predicts a high mortality that is multi-factorial. Hydrogen has been reported to alleviate organ injury via selective quenching of reactive oxygen species. This study investigated the potential protective effects of hydrogen against severe burn-induced early AKI in rats.

Methods

Severe burn were induced via immersing the shaved back of rats into a 100°C bath for 15 s. Fifty-six Sprague–Dawley rats were randomly divided into Sham, Burn + saline, and Burn + hydrogen-rich saline (HS) groups, and renal function and the apoptotic index were measured. Kidney histopathology and immunofluorescence staining, quantitative real-time PCR, ELISA and western blotting were performed on the sera or renal tissues of burned rats to explore the underlying effects and mechanisms at varying time points post burn.

Results

Renal function and tubular apoptosis were improved by HS treatment. In addition, the oxidation–reduction potential and malondialdehyde levels were markedly reduced with HS treatment, whereas endogenous antioxidant enzyme activities were significantly increased. HS also decreased the myeloperoxidase levels and influenced the release of inflammatory mediators in the sera and renal tissues of the burned rats. The regulatory effects of HS included the inhibition of p38, JNK, ERK and NF-κB activation, and an increase in Akt phosphorylation.

Conclusion

Hydrogen can attenuate severe burn-induced early AKI; the mechanisms of protection include the inhibition of oxidative stress induced apoptosis and inflammation, which may be mediated by regulation of the MAPKs, Akt and NF-κB signalling pathways.

Does the kidney injury molecule-1 predict cisplatin-induced kidney injury in early stage?

BACKGROUND

It is not possible to diagnose acute kidney injury (AKI) in early stages with traditional biomarkers. Kidney injury molecule-1 (KIM-1) is a novel biomarker promising the diagnosis of AKI in early stages. We studied whether urinary and serum KIM-1 (KIM-1 U and KIM-1 S ) concentrations were useful in predicting cisplatin-induced AKI in early stages.

METHODS

We prospectively analysed 22 patients on cisplatin treatment. KIM-1 S and KIM-1 U concentrations were assessed in the samples of the patients on four different time periods (before treatment [BT], first [AT1], third [AT3] and fifth [AT5] day after treatment).

RESULTS

KIM-1 U concentrations on the first day after cisplatin treatment in patients with AKI were significantly increased compared to both KIM-1 U concentrations of the same patients BT (P=0.009) and to AT1-KIM-1 U concentrations of the patients without AKI (P=0.008). A receiver operating characteristic analysis revealed that AT1-KIM-1 U concentrations may predict AKI with an 87.5% sensitivity and 93.3% specificity (area under the curve=0.94). KIM-1 S concentrations were not significantly changed between BT and AT periods.

CONCLUSIONS

KIM-1 U concentrations may predict cisplatin-induced AKI in early stages with high sensitivity and specificity.

Plasma neutrophil gelatinase-associated lipocalin as early biomarker for acute kidney injury in burn patients

This study evaluated whether measurements of plasma neutrophil gelatinase-associated lipocalin (NGAL) can predict acute kidney injury (AKI) in adult burn patients, and assessed the use of this biomarker in risk stratification. We performed a prospective observational study of consecutive patients with major burns admitted to the burn center within 12 hours of injury. Samples for plasma NGAL assay were obtained three times (at admission, day 3, and day 7). The main outcome measures were occurrence of AKI based on Risk-Injury-Failure classification and mortality. A total 45 patients with burns injury were enrolled. There was a high prevalence (11 of 45, 24.4%) of AKI in burn patients. All patients with AKI developed AKI after hospital day 8. Multivariate logistic regression analysis demonstrated that burn size and abbreviated burn severity index were independent risk factors of AKI. Patients who developed AKI had significantly higher admission plasma NGAL levels, hospital day 3 NGAL levels, and hospital day 7 NGAL levels. Especially, hospital day 7 NGAL levels strongly correlated with AKI. For concentration in plasma NGAL at hospital day 7, the area under the receiver operating characteristic curve was 0.903, sensitivity was 87%, and specificity was 91% for a cutoff value of 125 ng/ml. The mean plasma NGAL at hospital day 7 of patients who died was significantly higher than that of patients who did not (485 ng/ml vs 111 ng/ml, P = .001). Plasma NGAL levels are early predictive biomarkers for AKI and its clinical outcomes after burn injury.

Acute kidney injury defined according to the 'Risk,' 'Injury,' 'Failure,' 'Loss,' and 'End-stage' (RIFLE) criteria after repair for a ruptured abdominal aortic aneurysm

OBJECTIVE

Acute kidney injury (AKI) is a serious complication after repair of a ruptured abdominal aortic aneurysm (RAAA). In the present Society for Vascular Surgery (SVS)/International Society for CardioVascular Surgery (ISCVS) reporting standards patients are classified as no dialysis (grade I), as temporary dialysis (grade II), and as permanent dialysis or fatal outcome (grade III). However, AKI is a broad clinical syndrome including more than the requirement for renal replacement therapy. The recently introduced 'Risk,' 'Injury,' 'Failure,' 'Loss,' and 'End-stage' (RIFLE) classification for AKI comprises three severity categories based on serum creatinine and urine output ('Risk,' 'Injury,' and 'Failure'). The objective of the present study was to assess the incidence of AKI using the RIFLE criteria (AKIRIFLE). Secondary objectives were to assess the incidence of AKI as defined using the SVS/ISCVS reporting standards (AKISVS/ISCVS) and the association between AKIRIFLE and death.

METHODS

This was an observational cohort study in 362 consecutive patients with an RAAA in three hospitals in Amsterdam (The Netherlands) between 2004 and 2011. The end points were the incidence of AKIRIFLE, of AKISVS/ISCVS, and the combined 30-day or in-hospital death rate. A multivariable logistic regression model was made to assess the association between AKIRIFLE and death after adjustment for preoperative shock profile (Glasgow Aneurysm Score) and postoperative shock profile (Acute Physiology and Chronic Health Evaluation [APACHE] II score, use of vasopressors, and fluid balance during the first 24 hours after intervention).

RESULTS

AKIRIFLE occurred in 74% (267/362; 95% confidence interval [CI], 69%-78%), with 27% of these patients categorized as 'Risk' (71/267; 95% CI, 22%-32%), 39% categorized as 'Injury' (104/267, 95% CI, 33%-45%), and 34% categorized as 'Failure' (92/267; 95% CI, 29%-40%). AKISVS/ISCVS occurred in 48% (175/362; 95% CI, 43%-53%), with 53% of these categorized as 'grade I' (92/175; 95% CI, 45%-60%), 19% as 'grade II' (34/175; 95% CI, 14%-26%), and 28% as 'grade III' (49/175; 95% CI, 22%-35%). After multivariable adjustment for shock profiles the risk of dying in patients categorized as AKIRIFLE 'Failure' was greater than in patients without AKIRIFLE (adjusted odds ratio, 6.360; 95% CI, 2.231-18.130).

CONCLUSIONS

The incidence of AKI defined according to the RIFLE criteria (74%) was greater than defined using the SVS/ISCVS reporting standards (48%) and patients categorized as 'Failure' using the RIFLE criteria had a greater risk of dying than patients without AKI. These results indicate that the problem of AKI is much bigger than previously anticipated and that minimizing injury to the kidney could be an important focus of future research on reducing the death rate after RAAA repair.

Epidemiology, outcomes and validation of RIFLE and AKIN criteria in acute kidney injury (AKI) in critically ill patients: Indian perspective

Although the epidemiology and the impact of Acute Kidney Injury on outcomes are well-known in the Western literature, good data is lacking from India. Most studies published from India have not evaluated epidemiology of Acute Kidney Injury in the Intensive Care Unit setting and/or have not used validated criteria. In our observational study of 250 patients, admitted to a tertiary level ICU, we have explored the epidemiology of Acute Kidney Injury using both RIFLE and AKIN criteria and have validated them. We have also demonstrated that the severity of AKI is an independent predictor of mortality in critically ill patients. Our results are very much comparable to other studies and we feel that this study will remain as an epidemiological reference point for Indian clinicians dealing with AKI.

Genital burns in the national burn repository: incidence, etiology, and impact on morbidity and mortality

OBJECTIVE

To better characterize national genital burns (GBs) characteristics using a large burn registry. We hypothesized that mortality and morbidity will be higher in patients with GBs.

METHODS

The National Burn Repository, a large North American registry of hospitalized burn patients, was queried for patients with GB. Burn characteristics and mechanism, demographics, mortality, and surgical interventions were retrieved. Outcomes of interest were mortality, hospital-acquired infection (HAI), and surgical intervention on the genitalia. Adjusted odds ratios (aOR) for outcomes were determined with binomial logistic regression controlling for age, total burn surface area, race, length of stay, gender, and inhalation injury presence.

RESULTS

GBs were present in 1245 cases of 71,895 burns (1.7%). Patients with GB had significantly greater average total burn surface area, length of stay, and mortality. In patients with GB, surgery of the genitalia was infrequent (10.4%), with the aOR of receiving surgery higher among men (aOR 2.7, P <.001) and those with third-degree burns (aOR 3.1, P <.002). Presence of a GB increased the odds of HAI (aOR 3.0, P <.0001) and urinary tract infections (aOR 3.4, P <.0001). GB was also an independent predictor of mortality (aOR 1.54) even after adjusting for the increased HAI risk.

CONCLUSION

GBs are rare but associated with higher HAI rates and higher mortality after adjusting for well-established mortality risk factors. Although a cause and effect relationship cannot be established using these registry data, we believe this study suggests the need for special management considerations in GB cases to improve overall outcomes.

The year in burns 2012

Approximately 2457 research articles were published with burns in the title, abstract, and/or keyword in 2012. This number continues to rise through the years; this article reviews those selected by the Editor of one of the major journals in the field (Burns) and his colleague that are most likely to have the greatest likelihood of affecting burn care treatment and understanding. As done previously, articles were found and divided into these topic areas: epidemiology of injury and burn prevention, wound and scar characterization, acute care and critical care, inhalation injury, infection, psychological considerations, pain and itching management, rehabilitation, long-term outcomes, and burn reconstruction. Each selected article is mentioned briefly with comment from the authors; readers are referred to the full papers for further details.