Scand J Plast Reconstr Surg 13: 189-192, 1979
ACUTE RENAL FAILURE IN BURNS
D. M. Davies, C. D. Pusey, D. J . Rainford,
J. M. Brown and J. P. Bennett
From the Mclndoe Birrns Unit, Queen Victoria Hospital, East Grinsiead und the Renal Unit,
Princess Mary's Royal Air Force Hospital. Halton, England
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Abstract. We present the combined experience of a burns
unit and a renal dialysis unit in treating acute renal failure
in burn injury patients. A total of 28 cases have been
treated of whom 4 regained normal renal function. We
would like to emphasize the following points which may
improve the usually very poor prognosis: early diagnosis,
early daily haemodialysis, adequate feeding and the early
amputation of non viable limbs. A search of the literature
reveals that only 11 previously reported cases of burns
injury patients being successfully dialysed for acute renal
failure.
For personal use only.
The principal causes of death in burns patients are
respiratory failure, infection, metabolic abnormali-
ties, myocardial failure and renal failure. The over-
all incidence of established Acute Renal Failure is
low (Table I), although this may reflect under-
diagnosis. The problem becomes more important
with larger burns and older patients, and impaired
renal function may be an associated factor in the
death of many bums patients (Eklund, Gronberg &
Liljedahl, 1 9 7 0).~
The prognosis of patients with Acute Renal Fail-
ure has been grave. We feel that with early
diagnosis and adequate treatment the outlook for
these patients can be improved.
We present the combined experience of the
McIndoe Burns Unit, East Grinstead, and the Renal
Unit, Princess Mary's R.A.F. Hospital, Halton.
Haemodialysis of recent patients with Acute Renal
Failure at East Grinstead has been carried out by a
mobile dialysis team from Halton, providing the
patients with facilities and expertise for both
aspects of their management.
Since 1964, 1064 burns patients have been tre-
ated at East Grinstead, eight of whom have been
dialysed for Acute Renal Failure. Since 1958, 24
patients with Acute Renal Failure due to burns have
been treated by the Halton Renal Unit (4of these
at East Grinstead). The results are presented in
Table 11, and case histories of the four survivors
given.
CASE REPORTS
Crise 1
A 31-year-old man attempted suicide from an
electric pylon, and sustained full thickness electri-
cal burns to the occiput with exit burns on the left
arm. There were flash burns of the chest, and limbs
totalling 12%.
On admission he had myoglobinuria with granular
casts. Despite apparent adequate resuscitation he
became oliguric with a rising blood urea. His left
arm was amputated, and he was dialysed initially
peritoneally and later by haemodialysis for 11 days.
Renal function recovered fully, and further recon-
structive surgery to the occiput was carried out.
Cuse 2
A 54-year-old fireman sustained 52 % full thickness
flame burns at work, involving head and neck,
trunk, and limbs. Despite adequate resuscitation he
was oliguric from admission, and peritoneal dialysis
and high calorie oral feeding were commenced. A
diuresis ensued twenty days later, and renal func-
tion returned to normal. Several skin grafting opera-
tions were required, and he died two months later of
septicaemia and hepatic failure.
Cuse 3
A 36-year-old man sustained 52% flame burns in-
volving the trunk, thighs and left arm. He was ade-
quately resuscitated, but following excision and
skin grafting on the 5th day post burn he developed
 190 D . M . D m i e s et NI.

Table I. The incidence of acute r e n d fuilirre in biirns ( A . R . F . )und sirrvivors

Patients A.R.F. Survivors

Birmingham (1953-1%5), Cason, 1%6 3 690 49 9

U.S. Army (1960-1966), Vertel &
Knochel, 1967 I050 24 3
Guys (1953-1%7), Cameron &
Miller-Jones, 1%7 720 22 1
Roehampton (195!9-1966), Evans, 1969 602 0 0
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Table 11. Summary of treuted cuses

E. G . = treated at East Grinstead, H. = treated by Halton Renal Unit, P. D., = peritoneal dialysis, H. D. =
haemodialysis, Cons. = conservative management, Pneumonia = pulmonary problems including shock lung
% Treat- Duration
Case no. Age burn Aetiology ment (days) Outcome Commentlcause of death

53 52 Flame PD 20 Survived Died 2 months later,

(oliguria) hepatic failure
31 12 Electric PD/H II Survived Arm amputated
(oliguria)
29 16 Electric PD 8 Died Arm amputated, pneumonia
55 50 Flame HD 17 Died Pneumonia
38 42 Flame HD 4 Died Pneumonia
36 52 Flame HD 20 Survived Arm amputated. hyper-
(oliguria) baric 0, treatment,
For personal use only.

myocarditis
46 45 Flame HD 14 Died Pneumonia
29 75 Flame PD 6 Died Pneumonia
46 60 Flame PD/HD 5 Died Pneumonia
33 30 Electric HD 6 Died Toxaemia, peritonitis
58 40 Flame HD 5 Died Pneumonia, GI bleeding
10 50 Flame HD 9 Died Toxaemia
39 40 Flame HD 12 Died Septicaemia, pneumonia
51 17 Electric HD 10 Died Arm amputated, pneumonia
50 25 Flame Cons. 16 Died Septicaemia, peritonitis
63 17 Flame Cons. 4 Survived Arm and leg amputated,
(oliguria) myocardit is
7 65 Flame HD 7 Died Toxaemia
3 50 Flame PD 3 Died Toxaemia
17 60 Flame PD/HD 6 Died ?
53 25 Electric HD 2 Died Multiple injuries
65 15 Blast HD 6 Died Pneumonia, GI bleeding
22 80 Electric/ HD 8 Died Arm amputated, toxaemia
flame
22 85 Scald HD 6 Died Septicaemia, pneumonia
57 50 Flame HD 5 Died 'I

34 60 Flame Cons. ? Died ?

21 70 Flame PD 3 Died
4Y 45 Scald HD 3 Died ?
12 70 Flame HD 9 Died Septicaemia

non-oliguric Acute Renal Failure. Haemodialysis
was started, but 2 days later gas gangrene of the left
arm was diagnosed. Treatment with hyperbaric ox-
ygen was started, and the limb amputated. Further
eight daily treatments with hyperbaric oxygen re-
suited in the resolution of gas gangrene, and daily
dialysis for thirty days was required, before a
diuresis was obtained.
Full recovery of renal function occurred and
further grafting procedures were carried out. He
then developed a severe toxic myocarditis, which
resolved fully with medical treatment.

S c u d J Plus1 Reconstr Siirg I3


Table 111. Siirvivors of Jicr1ysi.s in brrrnrd pcrticwts
H = haemodialysis, P = peritoneal dialysis
Author A.E.T.
1958 Alwall, N . Electric
1960 Goldsmith Flame
1965 Alwall, N . Electric
1%5 Stephens Flame
1%7 Cameron ( 1 child, no details)
1%7 Dossetor Electric
Electric
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1971 Hartford Electric
1971 Marshall Electric
1973 Tagnor Electric
1974 Settle Flame
Case 4
A 63-year-old man accidentally fell on to a fire,
losing consciousness, and sustaining I7 % full
thickness burns of the right arm and leg. He be-
came oliguric despite fluid replacement, and had his
right leg amputated two days later. His Acute Renal
Failure was treated conservatively, and he im-
proved slowly obtaining a diuresis after 2 weeks.
For personal use only.
He subsequently required amputation of the right
arm, and recovered adequate renal function. He
died four months after the burns of toxic myo-
carditis, confirmed at post-mortem.
DISCUSSION
Renal function is affected by several aspects of
burns pathology, including hypovolaemia, lowered
cardiac output, increased sympathetic activity, re-
spiratory failure with hypoxia and acidosis, tox-
aemia and septicaemia (Eklund et al.). Most pa-
tients with severe burns have impaired renal func-
tion even when apparently adequately resuscitated,
the main abnormalities being disturbed osmolar
regulation and post-traumatic antidiuresis.
Signs of incipient renal failure, present before
decrease in urine output, nitrogen retention, or dis-
turbed electrolytes, have been described by Eklund
and by Settle (Eklund, 1970b, c; Settle, 1974). They
include: increased plasma creatinine and osmolali-
ty; decreased urine to plasma creatinine ratio; de-
creased creatinine clearance; increased ratio be-
tween osmolal and creatinine clearance, and a
changing urinary plasma osmolarity ratio becoming
fixed at 1.1. By frequent measurement of urinary
volumes and urinary and serum creatinine osmolali-
ty, the above indices can be follwed and earlier
Acrrtr rrtialjuilrrrr in birrris 191
Dialysis Comment
Hx3
Hx2
Hx3
Hx 1 Amputation
HxS Amputation
Hx7
Hx4 Amputation
PX 14 Amputation
(No details)
Px 10
diagnosis made. It is most important not to rely
solely on measurement of urine volume, as Acute
Renal Failure following burns is often non-oliguric
and delay in diagnosis will result.
Once the diagnosis of the established renal failure
has been made, dialysis should be instituted early.
Prognosis is improved if the blood urea can be kept
below 200 mg% (33.3 mmol/l) (Parsons, Hosbon,
Blagg & McCracken, 1961). These patients are all
intensely catabolic, and require high calorie feeding
of up to 5000 calories per day. This is best taken
orally if possible, but total parenteral feeding may
be indicated. Daily haemodialysis is required both
to control the rise in urea, and to remove the
obligatory fluid load from the feeding regime
(Flynn, 1967; Rainford, 1977). The patients will
often have associated respiratory and cardiovascu-
lar problems and provision of full “intensive care”
facilities is essential.
The surgical management of these patients is
necessarily limited. Early amputation of non-viable
limbs is, we believe, of great importance in their
management, as further renal damage may occur
from infection or liberated toxins. When the patient
is stable on dialysis, the burn wound can be grafted,
which will improve the patients condition and di-
minish chances of further infection.
Survival of burns patients with Acute Renal Fail-
ure is very rare, and we present the previously
reported survivors in the world literature in Table
111. It is interesting that four of the eleven cases had
amputations, as did three of our four survivors.
This point has been previously emphasized by Dos-
seter, Drummond, Allen, Celis & Baxter (1967).
The very high mortality of Acute Renal Failure in
burns contrasts with that generally found in surgical
Scuttcl J P ~Recoiis~r
I S w g I3
 192 D. M. Davies et al.
(53%) or traumatic (50%) cases (Flynn, 1974). We
believe that the gross metabolic disturbances, re-
lease of burn “toxins”, and high risk of severe in-
fection, are important factors. The majority of our
cases have died from septicaemic complications,
often with the pulmonary oedema of the “shock
lung syndrome”.
Bartlett (Bartlett, Gentile, Allyn, Nitta & Quasha,
1973) reported an interesting trial in which the
survival of comparable groups of patients with mas-
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sive bums (approximately 70 %) was prolonged
from 6.2 days to 22.5 days by daily dialysis. This
was attributed to control of uraemia, and possibly
to the dialysis of humoral toxic factors. The mode
of death was described as “metabolic”, and the
feeding of these patients was acknowledged to be
inadequate at 2 000-4 OOO calories per day.
CONCLUSION
The combined experience of a burns unit and an
acute renal failure unit in treating Acute Renal Fail-
For personal use only.
ure following burns injury is presented. We believe
that the extremely poor prognosis of these patients
can be improved, and that they should not be de-
nied treatment. Early diagnosis, prompt and ade-
quate haemodialysis, adequate feeding to meet the
catabolic response, early amputation of non-viable
limbs, aggressive treatment of infection, and full
“intensive care” facilities, appear to be required if
these patients are to survive.
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