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Acute kidney injury in patients with burns

Nature Reviews Nephrology volume 20, pages 188–200 (2024)Cite this article

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Abstract

Burn injury is associated with a high risk of acute kidney injury (AKI) with a prevalence of AKI among patients with burns of 9–50%. Despite an improvement in burn injury survival in the past decade, AKI in patients with burns is associated with an extremely poor short-term and long-term prognosis, with a mortality of >80% among those with severe AKI. Factors that contribute to the development of AKI in patients with burns include haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury, drug nephrotoxicity and sepsis. Early and late AKI after burn injury differ in their aetiologies and outcomes. Sepsis is the main driver of late AKI in patients with burns and late AKI has been associated with higher mortality than early AKI. Prevention of early AKI involves correction of hypovolaemia and avoidance of nephrotoxic drugs (for example, hydroxocobalamin), whereas prevention of late AKI involves prevention and early recognition of sepsis as well as avoidance of nephrotoxins. Treatment of AKI in patients with burns remains supportive, including prevention of fluid overload, treatment of electrolyte disturbance and use of kidney replacement therapy when indicated.

Key points

  • In patients with burns, acute kidney injury (AKI) is associated with an extremely poor short-term and long-term prognosis.

  • Alternative biomarkers of AKI such as cystatin C, proenkephalin and neutrophil gelatinase-associated lipocalin are associated with major adverse kidney events and improve the prediction of AKI.

  • Haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury and drug nephrotoxicity are key factors that contribute to AKI in patients with burns.

  • Prevention of early AKI mostly involves the correction of hypovolaemia and the avoidance of nephrotoxins such as hydroxocobalamin.

  • Sepsis is the main driver of late AKI in patients with burns and early recognition and prevention of sepsis is central to improving outcomes.

  • As no specific treatment for burn-induced AKI exists, current treatment remains supportive, including prevention of fluid overload, treatment of electrolytes disturbance and use of kidney replacement therapy when indicated.

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Fig. 1: Pathophysiology of AKI in patients with burns.
Fig. 2: Kidney insults and burden on renal reserve after burn injury.
Fig. 3: Haemodynamic profile and evolution after burn injury.
Fig. 4: Histological findings of oxalate nephropathy in a patient who received hydroxocobalamin after smoke inhalation injury.
Fig. 5: Role of biomarkers and artificial intelligence to guide the fluid resuscitation of severely ill patients with burns.

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Authors and Affiliations

  1. Department of Anaesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA

    Matthieu Legrand

  2. Department of General Surgery, Division of Burn, Trauma, Critical Care, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Audra T. Clark

  3. Department of Internal Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA

    Javier A. Neyra

  4. Department of Critical Care & Nephrology, King’s College London, Guy’s & St Thomas’ Hospital, London, UK

    Marlies Ostermann

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  3. Javier A. Neyra
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  4. Marlies Ostermann
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All authors researched data for the article, contributed substantially to discussion of the content, wrote the article and reviewed and/or edited the manuscript before submission.

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Correspondence to Matthieu Legrand.

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Competing interests

M.O. has received Speaker honoraria from Fresenius Medical, Baxter and bioMérieux and research funding from Fresenius Medical, LaJolla Pharma and Baxter; these competing interests are not directly related to the topic of this Review. J.A.N. has received consulting fees from Baxter, Leadiant Biosciences and Outset. M.L. and A.T.C. report no competing interests.

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Nature Reviews Nephrology thanks Kevin Chung, who co-reviewed with Nicholas Niazi, David Greenhalgh and the other, anonymous, reviewer for their contribution to the peer review of this work.

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Legrand, M., Clark, A.T., Neyra, J.A. et al. Acute kidney injury in patients with burns. Nat Rev Nephrol 20, 188–200 (2024). https://doi.org/10.1038/s41581-023-00769-y

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