Renal replacement therapy for acute kidney injury in major burns: An outcome analysis in an Asian tertiary center and a nationwide survey.

Abstract

Acute kidney injury (AKI) increases morbidity and mortality in major burns. We evaluated the impact of a standardized burn protocol implemented in 2015 (goal-directed fluid resuscitation, early albumin, and proactive renal replacement therapy [RRT] initiation) on RRT utilization and survival, and conducted a nationwide survey to benchmark current practices across burn centers in Taiwan. We performed a retrospective cohort study of major burn patients admitted to a tertiary burn center in Taipei from January 2003 to September 2023, divided into 2003-2014 and 2015-2023 cohorts. Inverse probability of treatment weighting (IPTW) with stabilized weights was used to account for baseline differences. Propensity scores were estimated from age, sex, TBSA, inhalation injury, burn mechanism, and burn depth. IPTW-weighted Cox models estimated hazard ratios for hospital mortality. A nationwide survey was distributed to 8 burn centers. Of 137 patients included, the 2015-2023 cohort had lower RRT use (20.3% vs. 42.9%, p = 0.008). Although TBSA was similar (p = 0.108), 28-day mortality (2.7% vs. 28.6%) and hospital mortality (8.1% vs. 47.6%) were significantly reduced (both p < 0.001). After IPTW adjustment, the 2015-2023 era remained associated with lower hospital mortality (HR 0.24, 95% CI: 0.10-0.55, p < 0.001). In the RRT subgroup (n = 42), hospital mortality fell from 85.2% to 40.0% (p = 0.005; IPTW-adjusted HR 0.38, 95% CI: 0.17-0.89, p = 0.025). CVVH was the predominant modality, and 66.7% of post-protocol RRT patients were initiated at KDIGO Stage 0-1. The survey revealed substantial variability in fluid resuscitation formulas and RRT initiation criteria. Implementation of a standardized burn protocol was associated with reduced RRT incidence and improved survival, with the 2015-2023 era retaining a significant mortality benefit after IPTW adjustment. Early, oliguria-based RRT initiation was associated with improved outcomes. Practice variability underscores the need for multicenter studies to establish consensus guidelines.