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Acute kidney injury is common, parallels organ dysfunction or failure, and carries appreciable mortality in patients with major burns: a prospective exploratory cohort study
Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Reconstruction Centre, Department of Plastic Surgery, Hand surgery UHL.
Linköping University, Department of Medicine and Health Sciences, Anesthesiology . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Surgery UHL.
Linköping University, Department of Clinical and Experimental Medicine, Burn Unit . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Reconstruction Centre, Department of Plastic Surgery, Hand surgery UHL.
2008 (English)In: Critical Care, ISSN 1364-8535, Vol. 12, no R124Article in journal (Refereed) Published
Abstract [en]

Introduction: The purpose of this study was to determine the incidence, time course, and outcome of acute kidney injury after major burns and to evaluate the impact of possible predisposing factors ( age, gender, and depth and extent of injury) and the relation to other dysfunctioning organs and sepsis.

Method: We performed an explorative cohort study on patients with a TBSA% (percentage burned of total body surface area) of 20% or more who were admitted to a national burn centre. Acute kidney injury was classified according to the international consensus classification of RIFLE ( Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease). Prospectively collected clinical and laboratory data were used for assessing organ dysfunction, systemic inflammatory response, and sepsis.

Results: The incidence of acute kidney injury among major burns was 0.11 per 100,000 people per year. Of 127 patients, 31 (24%) developed acute kidney injury (12% Risk, 8% Injury, and 5% Failure). Mean age was 40.6 years (95% confidence interval [CI] 36.7 to 44.5), TBSA% was 38.6% (95% CI 35.5% to 41.6%), and 25% were women. Mortality was 14% and increased with increasing RIFLE class (7% normal, 13% Risk, 40% Injury, and 83% Failure). Renal dysfunction occurred within 7 days in 55% of the patients and recovered among all survivors. Age, TBSA%, and extent of full thickness burns were higher among the patients who developed acute kidney injury. Pulmonary dysfunction and systemic inflammatory response syndrome were present in all of the patients with acute kidney injury and developed before the acute kidney injury. Sepsis was a possible aggravating factor in acute kidney injury in 48%. Extensive deep burns (25% or more full thickness burn) increased the risk for developing acute kidney injury early (risk ratio 2.25).

Conclusions: Acute kidney injury is common, develops soon after the burn, and parallels other dysfunctioning organs. Although acute kidney injury recovered in all survivors, in higher acute kidney injury groups, together with cardiovascular dysfunction, it correlated with mortality.

Place, publisher, year, edition, pages
2008. Vol. 12, no R124
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-16218DOI: 10.1186/cc7032OAI: oai:DiVA.org:liu-16218DiVA: diva2:133461
Available from: 2009-02-27 Created: 2009-01-09 Last updated: 2011-08-17Bibliographically approved
In thesis
1. Organ dysfunction among patients with major burns
Open this publication in new window or tab >>Organ dysfunction among patients with major burns
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The number of patients who are admitted for in-hospital care in Sweden because of burns is about 12/100,000, and only a small proportion of these have larger burns. Among them, and particularly among those who die in hospital, a condition referred to as “organ dysfunction” is common and an important factor in morbidity and mortality. The fact that the time of the initial event is known, and the magnitude of the insult is quantifiable, makes the burned patient ideal to be studied. In this doctoral thesis organ dysfunction and mortality were studied in a descriptive, prospective, exploratory study (no interventions or control groups) in patients admitted consecutively to a national burn centre in Sweden.

The respiratory dysfunction that is seen after burns was found to be equally often the result of acute respiratory distress syndrome and inhalation injury. We found little support for the idea that this early dysfunction is caused by pneumonia, ventilator-induced lung injury, or sepsis. Acute kidney injury (AKI) was also common, and mortality was associated with severity. Importantly, renal dysfunction recovered among the patients who survived. Pulmonary dysfunction and systemic inflammatory response syndrome developed before the onset of AKI. Sepsis was a possible aggravating factor for AKI in 48% of 31 patients; but we could find no support for the idea that late AKI was mainly associated with sepsis. We found that older age (over 60 years), greater TBSA%, and respiratory dysfunction were associated with increased mortality, but there was no association between the overall mortality and sex. We also found that early transient liver dysfunction was common, and recorded early hepatic “hyper”- function among many young adults. Persistent low values indicating severe liver dysfunction were found among patients who eventually died.

We conclude from this investigation that overall organ dysfunction is an early and common phenomenon among patients with severe burns. Our data suggest that the prognosis of organ dysfunction among these patients is good, and function recovers among most survivors. Multiple organ failure was, however, the main cause of death. The findings of the early onset in respiratory dysfunction and a delay in signs of sepsis are congruous with the gutlymphatic hypothesis for the development of organ dysfunction, and the idea of the lung as an inflammatory engine for its progression. We think that the early onset favours a syndrome in which organ dysfunction is induced by an inflammatory process mediated by the effect of the burn rather than being secondary to sepsis.

Our data further suggest that clinical strategies to improve burn care further should be focused on early interventions, interesting examples of which include: selective decontamination of the gastrointestinal tract to prevent translocation of gut-derived toxic and inflammatory factors; optimisation of fluid replacement during the first 8 hours after injury by goal-directed resuscitation; and possible improvement in the fluid treatment given before admission.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011. 70 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1248
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-70061 (URN)978-91-7393-155-7 (ISBN)
Public defence
2011-09-08, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2011-08-17 Created: 2011-08-17 Last updated: 2012-03-13Bibliographically approved

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Steinvall, IngridBak, ZoltanSjöberg, Folke

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