Clark Audra, Neyra Javier A, Madni Tarik, Imran Jonathan, Phelan Herb, Arnoldo Brett, Wolf Steven E
University of Texas Southwestern Medical Center, Department of Surgery, Division of Burn, Trauma, and Critical Care, Dallas, TX, USA.
University of Kentucky, Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism Lexington, KY, USA; University of Texas Southwestern Medical Center, Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, Dallas, TX, USA.
Burns. 2017 Aug;43(5):898-908. doi: 10.1016/j.burns.2017.01.023. Epub 2017 Apr 12.
Acute kidney injury (AKI) is a common and morbid complication after severe burn, with an incidence and mortality as high as 30% and 80%, respectively. AKI is a broad clinical condition with many etiologies, which makes definition and diagnosis challenging. The most recent Kidney Disease: Improving Global Outcomes (KDIGO) consensus guidelines defined stage and severity of AKI based on changes of serum creatinine and urine output (UOP) across time. Burn-related kidney injury is typically classified as early (0-3days after injury) or late (4-14days after injury). Early burn AKI is typically due to hypovolemia, poor renal perfusion, direct cardiac suppression from TNF-alpha, and precipitation of denatured proteins, while late AKI is often due to sepsis, multi-organ failure, and nephrotoxic drugs. Diagnosis can be difficult as UOP and biochemical markers can be relatively normal even with significant renal injury. A sensitive and specific biomarker for the early diagnosis of AKI is sorely needed, and multiple potential biomarkers are being investigated. For treatment, the reversal of the underlying cause is the first intervention. The advent of renal replacement therapy has significantly improved the mortality of burn patients with AKI and should be initiated early if injury progresses despite initial maneuvers. Unfortunately, no beneficial pharmacologic agents have been identified, despite multiple investigations. Of burn patients who survive AKI, the vast majority do not receive long-term hemodialysis and they are generally thought to have a good renal prognosis although this view is shifting. Preliminary data in the burn population suggest that AKI may confer an increased risk of end-stage renal disease and long-term all-cause mortality, but further research is needed.
急性肾损伤（AKI）是严重烧伤后常见且致命的并发症，其发病率和死亡率分别高达30%和80%。AKI是一种病因多样的广泛临床病症，这使得其定义和诊断具有挑战性。最新的改善全球肾脏病预后组织（KDIGO）共识指南根据血清肌酐和尿量（UOP）随时间的变化来定义AKI的分期和严重程度。烧伤相关的肾损伤通常分为早期（伤后0 - 3天）或晚期（伤后4 - 14天）。早期烧伤后AKI通常是由于血容量不足、肾脏灌注不良、肿瘤坏死因子-α对心脏的直接抑制以及变性蛋白质沉淀，而晚期AKI往往是由于脓毒症、多器官功能衰竭和肾毒性药物。由于即使存在严重肾损伤，UOP和生化标志物也可能相对正常，所以诊断可能会很困难。目前迫切需要一种用于早期诊断AKI的敏感且特异的生物标志物，并且正在对多种潜在生物标志物进行研究。对于治疗，首先要干预潜在病因。肾脏替代疗法的出现显著提高了烧伤合并AKI患者的生存率，如果尽管进行了初始处理但损伤仍进展，则应尽早开始肾脏替代疗法。不幸的是，尽管进行了多项研究，但尚未发现有益的药物。在从AKI中存活下来的烧伤患者中，绝大多数不需要长期血液透析，并且一般认为他们的肾脏预后良好，尽管这种观点正在发生变化。烧伤人群的初步数据表明，AKI可能会增加终末期肾病和长期全因死亡率的风险，但还需要进一步研究。
