Heng Xue, Li Haisheng
From the Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
Ann Plast Surg. 2025 May 1;94(5):528-535. doi: 10.1097/SAP.0000000000004178. Epub 2024 Dec 3.
Acute kidney injury (AKI) is common in severe burns with high mortality. Previous studies confirmed the renal replacement therapy (RRT) as an effective strategy in burn patients. However, the optimal timing of RRT initiation with AKI is rarely investigated.
We conducted a single-center, retrospective cohort study at a large burn center in Chongqing, China, from 2010 to 2020. Patients were grouped into early (initiated at Kidney Disease: Improving Global Outcomes stage 1 or 2 of AKI) and delayed RRT (initiated at Kidney Disease: Improving Global Outcomes stage 3 of AKI). The primary outcome was in-hospital mortality. The secondary outcomes included renal function recovery, length of stay, and RRT-related complications.
Of the included 79 patients, 42 and 37 were in early and delayed RRT group, respectively. The mean burn area was 68.82%. The in-hospital mortality tended to be higher in the early group (42.86%) than in the delayed group (29.73%, P = 0.227), although the difference was not statistically significant. The rate of partial remission of renal function at 48 hours after RRT discontinuation was significantly higher in the delayed group (78.26%) than early group (36.84%, P = 0.003). Furthermore, multivariable Cox and logistic regression analysis found that interval from AKI occurrence to RRT initiation was protective factors for 90-day mortality (hazard ratio 0.514, 95% confidence interval 0.349-0.756, P = 0.001), but fluid overload, acute respiratory distress syndrome, and multiple organ dysfunction syndrome were risk factors for mortality. Subgroup analysis revealed that patients with stage 1 or 2 AKI who received RRT within 24 hours after AKI had the lowest survival rate. In contrast, patients with stage 3 AKI who received RRT beyond 24 hours after AKI had the highest survival rate. The delayed group had higher rate of bleeding and lower rate of catheter-related infection than the early group.
Delayed initiation of RRT seemed to have similar survival benefits to early RRT initiation in burn patients with AKI, needing further confirmation by large randomized clinical study in future.
急性肾损伤（AKI）在严重烧伤患者中很常见，死亡率很高。先前的研究证实肾脏替代治疗（RRT）是烧伤患者的一种有效策略。然而，很少有人研究AKI患者开始RRT的最佳时机。
我们于2010年至2020年在中国重庆的一家大型烧伤中心进行了一项单中心回顾性队列研究。患者被分为早期组（在AKI的改善全球肾脏病预后组织1期或2期开始RRT）和延迟RRT组（在AKI的改善全球肾脏病预后组织3期开始RRT）。主要结局是住院死亡率。次要结局包括肾功能恢复、住院时间和RRT相关并发症。
纳入的79例患者中，早期RRT组和延迟RRT组分别有42例和37例。平均烧伤面积为68.82%。早期组的住院死亡率（42.86%）虽高于延迟组（29.73%），但差异无统计学意义（P = 0.227）。RRT停止后48小时肾功能部分缓解率在延迟组（78.26%）显著高于早期组（36.84%，P = 0.003）。此外，多变量Cox和逻辑回归分析发现，从AKI发生到开始RRT的间隔时间是90天死亡率的保护因素（风险比0.514，95%置信区间0.349 - 0.756，P = 0.001），但液体超负荷、急性呼吸窘迫综合征和多器官功能障碍综合征是死亡的危险因素。亚组分析显示，AKI 1期或2期患者在AKI后24小时内接受RRT的生存率最低。相反，AKI 3期患者在AKI后24小时后接受RRT的生存率最高。延迟组的出血发生率高于早期组，而导管相关感染发生率低于早期组。
在AKI烧伤患者中，延迟开始RRT似乎与早期开始RRT具有相似的生存益处，未来需要通过大型随机临床研究进一步证实。
