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(probability AND (acute kidney injury OR acute kidney failure OR acute renal injury OR acute renal
failure) AND burn injury) AND (Prognosis/Narrow[filter])11

J Burn Care Res. 2010 Jan-Feb;31(1):83-92.

Early acute kidney injury predicts progressive renal dysfunction and higher
mortality in severely burned adults.

Mosier MJ, Pham TN, Klein MB, Gibran NS, Arnoldo BD, Gamelli RL, Tompkins RG, Herndon DN.

University of Washington Burn Center at Harborview Medical Center, Seattle,WA 98104, USA.

Abstract
The incidence and prognosis of acute kidney injury (AKI) developing during acute resuscitation have not been well

characterized in burn patients. The recently developed Risk, Injury, Failure, Loss, and End-stage (RIFLE)

classification provides a stringent stratification of AKI severity and can allow for the study of AKI after burn injury. We

hypothesized that AKI frequently develops early during resuscitation and is associated with poor outcomes in

severely burned patients. We conducted a retrospective review of patients enrolled in the prospective observational

multicenter study "Inflammation and the Host Response to Injury." A RIFLE score was calculated for all patients at 24

hours and throughout hospitalization. Univariate and multivariate analyses were performed to distinguish the impact
 of early AKI on progressive renal dysfunction, need for renal replacement therapy, and hospital mortality. A total of

221 adult burn patients were included, with a mean TBSA burn of 42%. Crystalloid resuscitation averaged 5.2 ml/kg/

%TBSA, with urine output of 1.0 +/- 0.6 ml/kg/hr at 24 hours. Sixty-two patients met criteria for AKI at 24 hours: 23

patients (10%) classified as risk, 32 patients (15%) as injury, and 7 (3%) as failure. After adjusting for age, TBSA,

inhalation injury, and nonrenal Acute Physiology and Chronic Health Evaluation II > or =20, early AKI was associated

with an adjusted odds ratio 2.9 for death (95% CI 1.1-7.5, P = .03). In this cohort of severely burned patients, 28% of

patients developed AKI during acute resuscitation. AKI was not always transient, with 29% developing progressive

renal deterioration by RIFLE criteria. Early AKI was associated with early multiple organ dysfunction and higher

mortality risk. Better understanding of how early AKI develops and which patients are at risk for progressive renal

dysfunction may lead to improved outcomes.

Intensive Care Med. 2009 December; 35(12): 2125–2129. PMCID: PMC2779390

Published online 2009 September 15. doi: 10.1007/s00134-009-1638-6.
Copyright © The Author(s) 2009

An assessment of acute kidney injury with modified RIFLE

criteria in pediatric patients with severe burns
Tina Palmieri,1 Athina Lavrentieva, 2 and David Greenhalgh1
1
Shriners Hospital for Children Northern California, Burn ICU, Sacramento, USA
2
Papanikolau General Hospital, Burn ICU, Hadzipanagiotidi 2, 55236 Thessaloniki, Greece
Athina Lavrentieva, Phone: +30-694-9121458 begin_of_the_skype_highlighting +30-694-
9121458 end_of_the_skype_highlighting, Fax: +30-231-3307240, Email: alavrenti@gmail.com .
Corresponding author.
Received January 23, 2009; Revised July 9, 2009; Accepted August 4, 2009.

This article has been cited by other articles in PMC.

 Other Sections▼
o Abstract

o Introduction

o Methods

o Results

o Discussion

o References

Abstract
Objective
 To apply the modified pediatric RIFLE criteria for severity of acute kidney injury (AKI) to
pediatric burn ICU patients and to evaluate the overall incidence of AKI, risk factors for AKI and
influence of AKI on outcome.
Design
Retrospective, descriptive cohort study.
Setting
10-bed burn PICU facility.
Patients
All consecutive patients with a burn injury of 10% or more of total body surface area percentage
(TBSA, %) admitted during a 2 year period.
Measurements and results
Data of 123 patients were studied. The incidence of AKI was 45.5%. Patients with AKI tended to
have higher mortality than those without AKI (p = 0.057). All nonsurvivors attained pRIFLE
AKI by combination of serum creatinine and urine output criteria. Patients with a more severe
form of AKI (Failure and Injury) as well as patients with late AKI had more episodes of sepsis as
compared to patients with early AKI and the Risk category of AKI. Logistic regression analysis
indicated that PRISM score and TBSA were the independent risk factors for acute kidney injury
in pediatric burn patients; the presence of sepsis and septic shock were the independent risk
factors for the Failure class of AKI.
Conclusion
We observed a high incidence of AKI in the burn PICU population. Sepsis seems to contribute to
the development of the Failure class of AKI. Maximum Failure class of AKI is associated with
high mortality.
Keywords: Critically ill children, Burn, Acute kidney injury, RIFLE, Risk factors, Mortality

 Other Sections▼
o Abstract

o Introduction

o Methods

o Results

o Discussion
o References

Introduction
Acute kidney injury (AKI) has been associated with increased mortality, increased hospital
length of stay and increased healthcare resource use and costs in critical illness [1–4]. A
consensus definition of AKI using the RIFLE criteria was proposed by the Acute Dialysis
Quality Initiative working group [5]. Recently, Akcan-Arikan et al. [6] developed a modified
version of the RIFLE criteria for pediatric patients (pRIFLE) and reported a mortality of 60% in
children with AKI. [7]. Although some studies have applied the RIFLE classification system in
adult burn patients [8, 9], its usefulness in pediatric burn ICU patients has not been validated.
The objective of our study was to determine the incidence and characteristics of burned children
with AKI using the pRIFLE criteria, to identify risk factors for AKI and to describe the
association between AKI and outcome in critically ill children with burns.

 Other Sections▼
o Abstract

o Introduction

o Methods

o Results

o Discussion

o References

Methods
This study was approved by the Human Subjects Review Board at the University of California
Davis, USA, and did not require informed consent from the family. A retrospective study was
performed over a 2 year period (October 2006–September 2008) in a 10-bed specialized
pediatric burn ICU. All consecutive patients with a burn injury of 10% or more of total body
surface area (TBSA) admitted to the Shriners Hospital for Children Northern California Burn
Intensive Care Unit were included in the study. Exclusion criteria were: nonsurvivable burn
(decision for comfort care on admission), admission for non-burn diagnosis and burn size less
than 10%. Patient resuscitation was guided by the written treatment protocol of our ICU. Fluid
resuscitation in the first 48 h was based on the Parkland formula; thereafter, maintenance
crystalloid infusion rate was calculated using standard formulas for insensible wound fluid
 losses. Additional adjustments in crystalloid fluid infusion were guided by clinical and laboratory
findings. Early enteral nutrition was provided, and no prophylactic antibiotics were used.
Wounds were excised within 72 h of admission. Pediatric Risk of Mortality II (PRISM II) score
was used to grade the illness severity on admission to the PICU. Sepsis was diagnosed according
to current definition criteria and was recorded throughout ICU stay [10, 11]. Demographic and
clinical data were recorded for each patient, including length of ICU and hospital stay,
mechanical ventilation duration, abdominal compartment syndrome, nephrotoxic drugs
(aminoglycosides, vancomycin) and vasopressors (dopamine, epinephrine, norepinephrine),
inhalation or electrical injury. Intra-abdominal pressure was measured through the urinary
bladder pressure measurement method, and the abdominal compartment syndrome (ACS) was
defined as a sustained intra-abdominal pressure >20 mmHg that was associated with new organ
dysfunction/failure according to the International ACS Consensus Definitions Conference
recommendations [12]. Baseline estimated creatinine clearance (eCCL) was calculated using the
Schwartz equation from a serum creatinine measured within 3 months before ICU admission,
and if this was unavailable, the patients were assigned to a baseline eCCL of 120 ml/min/1.73 m2
[13, 14]. Patients were classified according to the maximum pRIFLE class (class R, class I and
class F) reached during their ICU stay. The pRIFLE class was determined based on the lowest
score for either eCCL or urine output. Patients who met any of the criteria of the pRIFLE
classification were classified as acute kidney injury patients. AKI is characterized as late if
kidney injury was observed after 5 postburn days. The ICU mortality was recorded.
Statistical analysis
Dichotomous and categorical variables were compared using the χ2 test; comparisons of location
parameters for continuous data were analyzed with Mann–Whitney and Kruskal–Wallis tests.
Risk factors were assessed with univariate analysis and the variables that were statistically
significant in the univariate analysis were included in the multivariate analysis by applying a
multiple logistic regression with AKI and Failure class of AKI as the dependent outcome
variables. In all comparisons, a p value of <0.05 was considered statistically significant. Data are
expressed as mean ± standard deviation (SD).

 Other Sections▼
o Abstract

o Introduction
o Methods

o Results

o Discussion

o References

Results
There were 221 consecutive admissions to the burn ICU over 2 years. Ninety-eight cases were
excluded: a priori decision to withdraw or withhold treatment upon entry to ICU (n = 8), burn
area less than 10% (n = 59), admission for non-burn diagnosis (n = 31). Data of the remaining
123 patients were evaluated.
The baseline estimated creatinine clearance (eCCL) was calculated using the Schwartz equation
only in 4 patients in whom the baseline serum Cr was available; the remaining 119 patients were
assigned to a baseline eCCL of 120 ml/min/1.73 m2.
Patient demographic and clinical characteristics are shown in Table 1.

Table 1
Characteristics of patients with and without AKI
No acute kidney injury Acute kidney injury
p value
(n = 67) (n = 56)
Age 7.4 ± 5.4 6.74 ± 5.4 ns
Gender (% of male) 70% 59% ns
PRISM on admission 4.5 ± 3.2 8.7 ± 6 <0.001
TBSA (%) on admission 22.6 ± 13 41.7 ± 17 <0.001
Electrical injury (%) 5.9% 7.1% ns
Inhalational injury (%) 16.4% 26.7% ns
Number of surgical procedures 1.3 ± 1.2 3.7 ± 2.8 <0.001
Abdominal compartment
0% 16% <0.001
syndrome (%)
Sepsis during ICU stay (%) 19.8% 38.4% <0.05
Nephrotoxic drugs (%) 25% 32.1% 0.08
Vasoactive drugs (%) 15.9% 35.7% <0.05
Length of mechanical ventilation
4.9 ± 6 23.3 ± 27 0.001
(days)
Length of ICU stay (days) 12.8 ± 11 36.7 ± 36 0.001
Length of hospital stay (days) 18 ± 13 51 ± 40 0.001
ICU mortality (%) 1.5% 8.9% 0.057
 AKI acute kidney injury; TBSA total burn surface area; PRISM Pediatric Risk of Mortality
score; ns nonsignificant; continuous variables, mean ± standard deviation (SD); categorical
variables, (%)
Intensive Care Med. 2009 December; 35(12): 2125–2129.
Published online 2009 September 15. doi: 10.1007/s00134-009-1638-6.
Copyright © The Author(s) 2009

Of the 56 patients with kidney injury, 37 had early and 19 had late AKI. Eighty-two percent of
patients with late AKI had septic episodes compared to 19% of patients with early occurrence of
AKI. The mortality rate of patients with early and late AKI was 5.4% (2 patients from 37) and
15.7% (3 patients from 19), respectively, p = 0.19.
Table 2 compares data of patient categories based on their attainment of RIFLE criteria by eCCL
only, by urine output only, or by the combination of both.

Table 2
Characteristics of patients with AKI (classification according to type of RIFLE criteria attained)
UO criteria, eCCL criteria, Both UO + eCCL
p value
n=9 n = 32 criteria, n = 15
Age (years) 2.3 ± 0.6 7.4 ± 5.5 6.7 ± 5.4 0.15
TBSA (%) 40 ± 25.9 41 ± 15.2 45.6 ± 21.7 0.65
PRISM 9 ± 4.6 8.7 ± 6.3 7.7 ± 5 0.4
Length of ICU stay (days) 44.3 ± 43.4 39.1 ± 38.3 31.5 ± 37.3 0.38
Length of hospital stay
52.8 ± 49.5 55 ± 47 66.3 ± 56 0.4
(days)
Length of mechanical
34.7 ± 46.3 23.9 ± 28.5 19.3 ± 22.7 0.59
ventilation (days)
Failure AKI class 0% 12.5% 40% <0.01
Mortality (%) 0 0 33.3 <0.001
UO urine output; eCCL estimated creatinine clearance; AKI acute kidney injury; TBSA total
burn surface area; PRISM Pediatric Risk of Mortality score; continuous variables,
mean ± standard deviation (SD); categorical variables, (%)
Intensive Care Med. 2009 December; 35(12): 2125–2129.
Published online 2009 September 15. doi: 10.1007/s00134-009-1638-6.
Copyright © The Author(s) 2009

Logistic regression analysis indicated that PRISM score (OR 1.3, 95% CI 1.1–1.4; p = 0.05) and
TBSA (OR 1.04, 95% CI 1.002–1.1; p < 0.001) were the independent risk factors for acute
kidney injury in pediatric burn patients; the presence of sepsis (OR 3.1, CI 1.2–5.9; p = 0.05) and
septic shock (OR 2.8, CI 1.1–6.02, p = 0.02) were the independent risk factor for the Failure
class of AKI.

 Other Sections▼
o Abstract

o Introduction

o Methods

o Results

o Discussion

o References

Discussion
In our study, the incidence of AKI of 45.5% in pediatric burn patients is lower than the incidence
of 58% reported by Plötz et al. [15] in general pediatric ICU patients. The diagnosis of AKI in
our patients was based mostly on the eCCL or on both urine output and eCCL criteria, and this
was based on a combination of urine output and eCCL in all non survivors. Aksan-Arican et al.
[6] also reported a higher mortality rate for pediatric patients who attained AKI by pRIFLE
creatinine criteria compared with patients attaining only pRIFLE urine output criteria.
Aggressive therapeutic strategies, such as Renal Replacement Therapy, in pediatric patients with
oliguria and/or anuria and creatinine elevation, may lead to a better survival rate.
Severity scores on admission have been shown to be useful tools for predicting occurrence of
AKI or the Failure class of AKI [9, 16, 17]. In our study, patients with AKI had higher TBSA and
PRISM scores on admission, with PRISM score and TBSA being risk factors for AKI in logistic
regression analysis. Patients with and without AKI did not differ in age, gender, or presence of
inhalational or electrical injury. Of note is the high incidence of inhalational injury observed in
patients of the Injury and Failure classes of AKI as compared to patients of the Risk category of
AKI.
Reported mortality in pediatric patients with renal failure and multiorgan failure from septic
complications is 50% [18–20]. In our study, patients with severe AKI (Injury and Failure) had
more episodes of sepsis and septic shock compared to patients with a Risk category of AKI. The
presence of sepsis seems to be the risk factor for the Failure class of AKI. The incidence of sepsis
was also significantly higher in patients who developed AKI after 5 postburn days, but these
patients did not have a higher mortality rate as compared to patients with early occurrence of
AKI.
 Although drug-related renal dysfunction is common in critically ill burn patients [9], we did not
observe significant differences in nephrotoxic drug use between patients with AKI and without
AKI. Severity of AKI was associated with increased use of nephrotoxic and vasoactive drugs.
This, as well as increases in bilirubin and thrombocytopenia, probably reflects disease severity
and sepsis.
The development of abdominal compartment syndrome in 40% of patients with the Failure class
of AKI is noteworthy. Intra-abdominal hypertension impairs systemic hemodynamics and renal
function and is a risk factor for renal failure [21].
The association of acute kidney injury and prognosis in burn patients has been described in
several studies [8, 9, 22]. In our study, patients with AKI tended to have a higher mortality rate
compared to patients without AKI; however, the mortality rate was much higher in the Failure
category as compared to the Risk and Injury classes. These findings are consistent with previous
studies addressing the severity of AKI and outcome [16, 23].
This study has several limitations. First, this study was conducted at a single institution and in a
relatively small number of patients. Secondly, the retrospective observational study design
precludes any powerful conclusions as to the causative relationship between AKI and mortality.
We conclude that a pRIFLE classification system can serve well to improve understanding of
AKI epidemiology in critically ill pediatric burn patients. Information on the overall incidence of
AKI, risk factors for AKI and the influence of AKI on outcome in pediatric patients with severe
burn injury may be useful in the design of larger multicenter trials in order to determine the
contribution of AKI to patients’ morbidity and mortality and to evaluate the effect of early
initiation of aggressive measures to both prevent and treat AKI in pediatric burn ICU patients.

Open Access
This article is distributed under the terms of the Creative Commons Attribution Noncommercial
License which permits any noncommercial use, distribution, and reproduction in any medium,
provided the original author(s) and source are credited.

 Other Sections▼
o Abstract

o Introduction

o Methods
o Results

o Discussion

o References

References
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5. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, and the Acute Dialysis Quality Initiative (ADQI) Workgroup
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7. Flynn JT (2002) Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 17:61–69
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8. Lopes JA, Jorge S, Neves FC, Caneira M, da Costa AG, Ferreira AC, Prata MM (2007) An assessment of the RIFLE
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Ivatury R, D’Amours S, Wendon J, Hillman K, Johansson K, Kolkman K, Wilmer A (2006) Results from the International
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J Burn Care Res. 2008 Jan-Feb;29(1):227-37.

Acute renal failure in intensive care burn patients (ARF in burn patients).

Mustonen KM, Vuola J.

Helsinki Burn Centre, Department of Plastic Surgery, Helsinki University Hospital, Finland.

Abstract
The purpose of this study was to establish the incidence and mortality of burn patients with acute renal failure (ARF)

at the Helsinki Burn Centre and to analyze the associated factors. The files of 238 intensive care (ICU) patients of a

total of 1380 burn patients admitted to our institution between November 1988 and December 2001 were studied

retrospectively. Of all admitted burn patients, 17.2% needed ICU. According to our criteria (S-Cr >120 micromol/l =

1.4 mg/dl), 39.1% of the ICU patients suffered from ARF and one in three of these required renal replacement

therapy. The proportion of all admitted burn patients requiring renal replacement therapy was 2.3%. The mortality of

ICU patients with ARF was 44.1% whereas that of patients without ARF was only 6.9%. Renal function recovered in

all survivors. The nonsurvivors had a larger burned total body surface area, were older, and had more inhalation

injuries and a higher abbreviated burn severity index score. The prognosis for patients with early ARF was worse than

that for patients with late ARF. Rhabdomyolysis caused by flame injury was associated with high mortality. In this

study we observed that ARF is associated with higher mortality even in minor burns when compared with patients

without ARF. Flame burn with rhabdomyolysis and subsequent ARF predicts very poor survival. If a patient with

severe ARF survives, the renal failure recovers over time.

Am J Nephrol. 2003 Jan-Feb;23(1):55-60.

Impact of burn size and initial serum albumin level on acute renal failure
occurring in major burn.

Kim GH, Oh KH, Yoon JW, Koo JW, Kim HJ, Chae DW, Noh JW, Kim JH, Park YK.
Department of Internal Medicine, Hallym University College of Medicine, Kangwon Do, South Korea.

gheunho@hanmail.net

Abstract
BACKGROUND: Acute renal failure (ARF) is not a rare occurrence in severe burns and is an important complication

leading to an increase in mortality. The severity of the burn is largely determined by the burn size, and severe burns

are likely to cause enough loss of extracellular fluid and albumin from plasma volume to produce shock and

hypoalbuminemia. HYPOTHESIS: We hypothesized that initial serum albumin level may be useful as an indicator of

prognosis and severity of injury in burned patients. METHODS: The clinical characteristics of 147 adult patients with

second- and third-degree burns covering 30% or more of their body surface area were analyzed retrospectively.

Logistic regression was used to estimate the relative risks of ARF and mortality associated with the larger burn size

and the lower serum albumin level at admission. RESULTS: Mean burned body surface was 60.0 +/- 21.8% (range

30-100%). Twenty-eight (19.0%) out of 147 patients experienced ARF, defined as a serum creatinine > or = 2 mg/dl,

during the admission. The patients with ARF had larger burn size (79.5 +/- 15.4 vs. 55.3 +/- 20.5%, p < 0.0001) and

lower serum albumin concentration at admission (1.92 +/- 0.66 vs. 2.48 +/- 0.82 g/dl, p < 0.0005) compared with

those without ARF. All patients with ARF expired, whereas 29.4% (35/119) of the patients without ARF died. The burn

size > or = 65% was associated with a risk of ARF that was 9.9 times and with a risk of death that was 14.2 times as

high as that for the burn size <65%. The initial serum albumin level <2.5 g/dl was associated with a risk of death that

was 2.7 times as high as that for the initial serum albumin level > or = 2.5 g/dl. CONCLUSIONS: When major burns

are complicated by ARF, the mortality rate increases significantly. Burn size is an independent predictor of ARF

occurring in major burns. Initially depressed serum albumin level is associated with an increase in mortality in the

major burn patients. Copyright 2003 S. Karger AG, Basel

probability AND (acute kidney injury OR acute kidney failure OR acute renal injury OR acute renal failure)
AND sever* burn injury) AND (Prognosis/Narrow[filter]) 9

J Burn Care Res. 2010 Jan-Feb;31(1):83-92.

EARLY ACUTE KIDNEY INJURY PREDICTS PROGRESSIVE RENAL DYSFUNCTION AND HIGHER MORTALITY

IN SEVERELY BURNED ADULTS.

Mosier MJ,
MJ, Pham TN,
TN, Klein MB,
MB, Gibran NS,
NS, Arnoldo BD,
BD, Gamelli RL,
RL, Tompkins RG,
RG, Herndon DN.
DN.

University of Washington Burn Center at Harborview Medical Center, Seattle,WA 98104, USA.

Intensive Care Med. 2009 December; 35(12): 2125–2129. PMCID: PMC2779390

Published online 2009 September 15. doi: 10.1007/s00134-009-1638-6.

Copyright © The Author(s) 2009

AN ASSESSMENT OF ACUTE KIDNEY INJURY WITH MODIFIED RIFLE CRITERIA IN PEDIATRIC PATIENTS

WITH SEVERE BURNS

Tina Palmieri,1 Athina Lavrentieva, 2 and David Greenhalgh1

1Shriners Hospital for Children Northern California, Burn ICU, Sacramento, USA

2Papanikolau General Hospital, Burn ICU, Hadzipanagiotidi 2, 55236 Thessaloniki, Greece

Athina Lavrentieva, Phone: +30-694-9121458 begin_of_the_skype_highlighting +30-694-

9121458 end_of_the_skype_highlighting, Fax: +30-231-3307240, Email: alavrenti@gmail.com .

Corresponding author.

Received January 23, 2009; Revised July 9, 2009; Accepted August 4, 2009.

J Burn Care Res. 2008 Jan-Feb;29(1):227-37.

ACUTE RENAL FAILURE IN INTENSIVE CARE BURN PATIENTS (ARF IN BURN PATIENTS).

Mustonen KM,
KM, Vuola J.
J.

Helsinki Burn Centre, Department of Plastic Surgery, Helsinki University Hospital, Finland.

Am J Nephrol. 2003 Jan-Feb;23(1):55-60.

IMPACT OF BURN SIZE AND INITIAL SERUM ALBUMIN LEVEL ON ACUTE RENAL FAILURE OCCURRING IN

MAJOR BURN.

Kim GH,
GH, Oh KH,
KH, Yoon JW,
JW, Koo JW,
JW, Kim HJ,
HJ, Chae DW,
DW, Noh JW,
JW, Kim JH,
JH, Park YK.
YK.

Department of Internal Medicine, Hallym University College of Medicine, Kangwon Do, South Korea.

gheunho@hanmail.net

“Acute renal failure in intensive care burn patients (ARF in burn patients)” related citations 787 1-
100

Burns. 1999 Mar;25(2):171-8.

Acute renal failure in severely burned patients.

Holm C, Hörbrand F, von Donnersmarck GH, Mühlbauer W.

Department of Plastic and Reconstructive Surgery, Hand Surgery, Burn Center, Krankenhaus München-

Bogenhausen, Academic Teaching Hospital, Technical University Munich, Germany. wmuehlbauer@t-online.de

Abstract
Acute renal failure (ARF) is a well known complication of severe burns and is an important factor leading to an

increase in mortality. In order to analyze possible pathogenetic and prognostic factors associated with ARF in burned
patients we reviewed in a retrospective study the files of 328 patients with burns > 10% body surface area (BSA),

admitted to our burn unit between 01.01.94 and 01.05.98. We found 48 patients with acute renal failure

corresponding with an incidence of 14.6%. Patients with ARF had a mean burned surface area of 48% (13-95) and an

abbreviated burn severity index score (ABSI) of 9.8 (4-15). Thirty eight (79%) of these patients had an inhalation

injury diagnosed. Renal insufficiency was divided in a late and an early form depending on its time of onset and we

found 15 (31%) patients with ARF occurring within the first 5 days of the hospital stay and 33 (69%) patients with ARF

developing >5 days following the thermal injury. The incidence of myoglobinuria and hypotension during the

resuscitation phase was significantly higher in the group with early ARF, whereas patients with late ARF presented

sepsis more frequently than patients with early occurring renal failure. Accordingly, potential nephrotoxic antibiotics

were administered more often in patients with late ARF. Patients with ARF were treated by continuous arteriovenous

hemofiltration (CAVH) for a mean period of 10.5 days (1-47) and CAVH was associated with a complication rate of

10%. Most of the complications were associated with the vascular access in the femoral artery. The mortality rate in

patients with ARF was 85% and death was due to multiple organ failure in 83% of the cases. Only burned BSA and

inhalation injury proved to be significantly correlated with the development of ARF, whereas age, third degree burn or

electric injury were not significantly different between the two groups. Neither age, TBSA, day of onset of ARF nor

duration of the renal replacement therapy proved to be significantly different comparing survivors with non-survivors,

and thus predictive for the survival rate.

Srp Arh Celok Lek. 1996 Sep-Oct;124(9-10):241-5.

[Acute renal insufficiency caused by burn injury]

[Article in Serbian]

Zogović J, Mladenović Lj.

Department of Nephrology, Military Medical Academy, Belgrade.

Abstract
Acute renal failure (ARF) in burn disease results in a range of phenomena important not only from theoretical, but

also from practical point of views, whose causes are manifold. ARF is generally defined as a rapid renal failure
resulting in accumulation of protein metabolism degradation products (catabolism). It has been known, for some time,

that thermal agents do not produce only local skin damages, but also disturb the integrity of the whole organism

producing major functional damages of all organs and systems. Most frequently organs affected by burn disease are

the following: the lungs, the heart, the kidney, the liver and blood coagulation systems. There are many factors

influencing the renal function during the burns. The most important are: decreased cardiac output, respiratory failure

with hypoxia and acidosis, toxaemia and sepsis [1, 4, 6 7, 8-10, 12, 19]. ARF in burn disease may be early due to

hypovolaemia and hypoperfusion of the kidneys or late, occurring after a week as a consequence of infection and

endotoxaemia. Development of ARF in burn disease is a very unfavorable prognostic sign necessitating a complex

evaluation. Anuria in an early phase of burn disease may indicate the development of ARF, particularly if urine

findings are positive to haemoglobin, proteins, myoglobin, which is of the utmost importance in deep burns inflicted by

high voltage current. The immediate cause of anuria in burn disease may be a reflex transfer and penetration of the

large quantities of toxic materials into the circulation form the region affected by burns leading to the spasm of

afferent glomerular arteriolae producing sudden discontinuation of glomerular filtration. After burns, sudden increase

in the osmotic activity ensues in the affected tissue. Some low molecular links may result, and such particles tend to

change the osmotic balance and stimulate the development of oedema, and if not excreted, they increase osmolarity.

In 20-30% of the patients with burn disease anuria is absent [2, 5, 11, 14, 18, 20]. The genesis of burn disease-

associated anaemias is therefore multifactorial. These factors are the following: haemorrhage, haemolysis and

etrythropoiesis level decrease. In massive burns, large amounts of non-specific inflammatory components are

produced as well: prostaglandins, histamine, quinines leukocyte phenomena, bacterial toxins, etc. [1, 6, 13-16]. The

study based on a years-long treatment of our patients with burn disease included on 100 patients. The youngest of

the patients was 14 years old, and the oldest 65 years. The percent of burns-affected body surface ranged from 25%

to 75%. In 3/4 of the patients the picture of an early renal failure developed, with oliguria immediately after infliction of

the burns with rapid increase of serum urea and creatinine levels, while in 1/4 of the patients ARF occurred on the

eighth day following the infliction of the burns. "late form of acute renal failure". Among our series with burn disease,

anuria was present in 34.0% of patients and oliguria in 25.0%. ARF (early phase) occurred in 59 patients, 38 patients

had no sing of ARF, while late ARF developed only in 3 patients. ARF-associated mortality rate was high among these

patients (23%), being 6% among anuric patients with ARF and 17% in patients with ARF with anuria. Seventy-seven

percent of the patients survived, and their serum and urine analyses performed upon subsequent out-patient follow-

up examinations ranged within normal values. Such high percentage of survival among our patients included in the

study is based on an early diagnosis of ARF, understanding of pathophysiology of shock associated with burn
disease, adequate therapeutic approaches, including both medicamentous treatment and extracorporeal

haemodialysis along with early surgical management (Shema 1, 2). For the time being, haemodialysis is the most

effective therapeutical procedure in the treatment of ARF, although the mortality rate of dialyzable patients

Am J Nephrol. 2003 Jan-Feb;23(1):55-60.

Impact of burn size and initial serum albumin level on acute renal failure occurring in major burn.

Kim GH,
GH, Oh KH,
KH, Yoon JW,
JW, Koo JW,
JW, Kim HJ,
HJ, Chae DW,
DW, Noh JW,
JW, Kim JH,
JH, Park YK.
YK.

Department of Internal Medicine, Hallym University College of Medicine, Kangwon Do, South Korea.

gheunho@hanmail.net

J Burn Care Res. 2010 Jan-Feb;31(1):83-92.

Early acute kidney injury predicts progressive renal dysfunction and higher
mortality in severely burned adults.

Mosier MJ,
MJ, Pham TN,
TN, Klein MB,
MB, Gibran NS,
NS, Arnoldo BD,
BD, Gamelli RL,
RL, Tompkins RG,
RG, Herndon DN.
DN.

University of Washington Burn Center at Harborview Medical Center, Seattle,WA 98104, USA.

G Ital Nefrol. 2002 Mar-Apr;19(2):155-9.

[Dialytic therapy in severely burnt patients with acute renal failure]

[Article in Italian]

Triolo G, Mariano F, Stella M, Salomone M, Magliacani G.

Dipartimento di Area Medica, U. O. Autonoma di Nefrologia e Dialisi, Torino, Italy.

Abstract
BACKGROUND: Appearance of acute renal failure (ARF) in severely burnt patients (GU) is a serious complication. It

has a negative prognostic value and almost always develops in the context of multiple organ dysfunction syndrome

(MODS) induced by sepsis. Over the last 20 years, according to data available, the mortality rate has been reported

to reach about 75%. We have analyzed the initial results obtained in GU patients who were admitted to the Intensive

Care Unit of the Burns Center in Turin. METHODS: Out of 105 GU patients admitted between July 1999 and

September 2000 (burned surface area (BSA) 23.8%, range 2-95%, mortality rate 13.7%), 7 patients (6.4%) had

complications of ARF requiring extracorporeal dialytic therapy (38 HF sessions lasting 4-6 hours, 2 HF + 12 HDF + 1

UF sessions lasting 8-11 hours). RESULTS: Total BSA of 7 GU patients with ARF was 62.5+/-11.3% (mean +/-SEM).

Mortality rate was 71.4% which was due to septic shock and MODS. ARF onset was at 28.4+/-8.4 days from

admission. Dialytic treatment started at Crs 2.3+/-0.42 mg/dl, and patients were treated for 7.6+/-3.5 days with a

weight loss of 1859+/-161 gr/die. Circuit anticoagulation was obtained by minimal amount of heparin (132.2+/-26.5

U/hour) and no hemorrhagic complications were observed. CONCLUSIONS: In GU patients with ARF the dialytic

treatment with daily long-lasting convective- diffusive techniques permitted us to achieve a survival and dialytic

adequacy similar to those reported with continuous renal replacement therapies; however, mortality rate is high and

related to septic shock and MODS.

Saudi J Kidney Dis Transpl. 2009 Jul;20(4):632-8.

Early markers of renal injury in predicting outcome in thermal burn patients.

Sabry A, Wafa I, El-Din AB, El-Hadidy AM, Hassan M.

Nephrology Department, Mansoura Urology and Nephrology Center, Egypt. asabry2040@yahoo.com

Abstract
Acute renal failure (ARF) is a well known complication of severe burn and is an important factor that can increase

mortality. To determine the predictors of acute renal failure that occur in major burns, we studied 40 patients with

moderate to severe thermal burn injury - second to third degree with > 20% of total body surface area. All patients

were subjected to routine investigations including: Serum creatinine, blood urea nitrogen, fractional excretion of
sodium, urinary malondialdehyde and microalbuminuria on day 0, 3, 7, 14 and 21 of hospitalization. Nine patients

(22.5 %) developed acute renal failure; 4 patients required supportive dialysis. The group that developed ARF

showed an increase of markers of glomerular damage with appearance of micro-albuminuria on day 0 that reached 3

- 4 folds above its normal level on day 14 and remained constant with elevated serum creatinine and burn size in the

3 rd week of ARF, and progressed to overt proteinuria in 3 cases. Urinary malondialdehyde increased 3 folds above

normal values before developing acute renal failure, and gradually increased on day 14, which coincided with the

increased of microalbuminuria. Two cases (22.2%) in the ARF group who developed septicemia and required dialysis

died on the 32 nd and 36 th days post-burn. Burn size and occurrence of septicemia were the only predictors of acute

renal failure using multiple regression analysis (P value < 0.001 and < 0.0371, respectively). We conclude that acute

renal failure complicates burn patients and is related to the size and depth of burn and occurrence of septicemia.

Microalbuminuria and urinary malondialdehyde are useful markers for prediction of renal outcome in such group of

patients.

Med Intensiva. 2006 Nov;30(8):363-9.

[Epidemiology, initial management and analysis of morbidity-mortality of

severe burn patient]

[Article in Spanish]

Curiel-Balsera E, Prieto-Palomino MA, Fernández-Jiménez S, Fernández-Ortega JF, Mora-Ordoñez J, Delgado-

Amaya M.

Unidad de Cuidados Intensivos, Hospital Regional Carlos Haya, Málaga, España. emiliouci@ya.com

Abstract
OBJECTIVE: Describe the epidemiological characteristics of severe burn patients and analyze the factors related

with morbidity-mortality. DESIGN AND SCOPE: Observational, retrospective study of patients admitted to an

intensive care unit of a level III hospital due to severe burns from January 1998 to December 2004. PATIENTS: 59

patients with criteria of "severe burn" and expected stay in ICU greater than three days. MAIN ENDPOINTS OF

INTEREST: We studied epidemiological endpoints of this type of patients, diagnosis and initial treatment, early
complications and morbidity-mortality. RESULTS: The burned body surface was 41% +/- 25% and age 49 +/- 21

years. Patients remained hospitalized in ICU for a median of 4 days (interquartile range: 2-19). A total of 78% of the

patients needed mechanical ventilation, 47% had some infection during admission and 28% developed acute kidney

failure during the first week. Mortality in the ICU was 42%. Endpoints associated independently with a significant

increase of mortality were burned body surface greater than 35% (OR 1.08; 95% CI: 1.03-1.12) and development of

kidney failure (OR 5.47; 95% CI: 2.02 -8.93). CONCLUSIONS: Mortality of these patients is very high and is

conditioned largely by initial care. Percentage of burned body surface (BBS) and kidney failure entails greater

mortality in our series.

J Trauma. 1999 Jan;46(1):141-4.

Acute renal dysfunction in severely burned adults.

Chrysopoulo MT, Jeschke MG, Dziewulski P, Barrow RE, Herndon DN.

Department of Surgery, Shriners Hospitals for Children and University of Texas Medical Branch, Galveston 77550,

USA.

Abstract
BACKGROUND: Factors contributing to mortality in burned children with acute renal failure have been identified;

however, they have not been identified in thermally injured adults. METHODS: The records of 1,404 acutely burned

adults admitted to the Blocker Burn Unit were reviewed. Seventy-six patients with acute renal dysfunction and burns

covering more than 30% of their total body surface area with a full-thickness component greater than 10% total body

surface area were identified. These patients were divided into those admitted from 1981 through 1989 (n = 35) and

those admitted from 1990 to 1998 (n = 41). RESULTS: No significant differences could be shown in the incidence of

acute renal dysfunction (5.4 vs. 5.1%) or mortality (88 vs. 87%) for the two time periods, respectively. Sixty-seven

percent of the survivors were younger than 40 years of age, compared with only 25% of nonsurvivors (p < 0.02);

sepsis was identified in 44 and 96% of survivors and nonsurvivors, respectively (p < 0.001). Fluid resuscitation was

delayed in survivors by 1.7+/-1.0 hours compared with 4.4+/-2.1 hours in nonsurvivors (p < 0.001). CONCLUSION:
early fluid resuscitation and the prevention of sepsis may reduce the incidence of acute renal dysfunction and

mortality in burned adults.

Am J Kidney Dis. 2007 Apr;49(4):517-23.

Contribution of acute kidney injury toward morbidity and mortality in burns: a

contemporary analysis.

Coca SG, Bauling P, Schifftner T, Howard CS, Teitelbaum I, Parikh CR.

Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT 06516, USA.

Abstract
BACKGROUND: Severe acute kidney injury (AKI) that requires dialytic support, a relatively uncommon complication

in severely burned adults, is associated with a substantially increased mortality rate. It is not known whether milder

forms of AKI have prognostic importance in burns. METHODS: We performed an observational cohort analysis of

consecutive patients with major burns admitted to the burn care unit of a tertiary-care center from 1998 to 2003. Our

main outcome measures were AKI stratified by the Risk of renal dysfunction, Injury to the kidney, Failure of kidney

function, Loss of kidney function, and End-stage kidney disease (RIFLE) classification and mortality. RESULTS: AKI

occurred in 81 of 304 patients (26.6%) with burns on 10% or greater total-body surface area. Risk factors for AKI on

multivariate analysis were inhalational injury, catheter infection, and sepsis. Patients with AKI stratified by using the

RIFLE classification had greater mortality, greater requirement of artificial ventilation, and longer durations of

intensive care unit and hospital stays. Mortality was not significantly different among those with the "Risk" and "Injury"

strata of RIFLE AKI compared with those without AKI, but mortality increased significantly with the "Failure" (60%)

strata. In multivariate analysis, age, greater total-body surface area, inhalational injury, and the RIFLE classification of

Failure were each independent predictors of death. CONCLUSION: In conclusion, the mortality of patients with burns

with severe AKI remains high and unchanged in the modern era of critical care medicine. The RIFLE classification

added prognostic information regarding morbidity in patients with milder forms of AKI.
QJM. 2005 Sep;98(9):661-6. Epub 2005 Jul 29.

Severe acute renal failure in adults: place of care, incidence and outcomes.

Hegarty J, Middleton RJ, Krebs M, Hussain H, Cheung C, Ledson T, Hutchison AJ, Kalra PA, Rayner HC, Stevens

PE, O'Donoghue DJ.

Department of Renal Medicine, Hope Hospital, Stott Lane, Salford, Manchester M6 8HD, UK.

janet.hegarty@srht.nhs.uk

Abstract
BACKGROUND: Department of Health guidelines recommend specialist critical care facilities for patients with severe

single-organ failure such as acute renal failure (ARF). Prospective studies examining incidence, causes and

outcomes of ARF outside of intensive care settings are lacking. AIM: To determine the incidence, causes, place of

care and outcomes of severe single-organ ARF. DESIGN: Prospective observational study. METHODS: For 6 weeks

in June-July 2003, renal physicians were contacted daily, and ICUs on alternate days, to identify cases of severe

single-organ ARF in the Greater Manchester area. All patients with serum creatinine >or=500 micromol/l and not

requiring other organ support were included. Patients with end-stage renal disease were excluded. Survivors were

followed up at 90 days and 1 year from admission. Two independent consultant nephrologists assessed each case

using anonymized summaries. RESULTS: Eighty-five patients had multi-organ ARF and 28 had severe single-organ

ARF (380 and 125 pmp/year, respectively). Of those with single-organ ARF, 10 (36%) had known pre-existing chronic

kidney disease. Renal replacement therapy (RRT) was required in 15 (54%). Total bed occupancy on ICUs relating to

single-organ ARF was 59 days (range per patient 1-21). At 90 days, 18 (64%) were alive, and 17 (94%) had

independent renal function. At 1 year, 4/18 had died, none receiving RRT at the time of death. Survivors all had

independent renal function. In 13 (46%) cases there was an unacceptable delay in patient transfer and in 7 (25%),

delays in assessment or commencement of RRT may have adversely affected patient outcome. DISCUSSION: The

incidence of ARF treated with RRT is rising. Delays in transfer to renal services may result in inappropriate ICU bed

use, and may adversely affect patient outcomes. There are serious problems regarding the appropriate use of

expensive and limited medical resources in the critical care area, and in providing safe and effective treatment of

patients with ARF.