Management of Burns Complicated by Acute Kidney Injury (AKI)

Initial Fluid Resuscitation

Adult burn patients with total burned body surface area (TBSA) ≥15% and pediatric burn patients with TBSA ≥10% should receive 20 mL/kg of intravenous crystalloid solution within the first hour of management 1, 3
Balanced crystalloid solutions, particularly Ringer's Lactate, should be used as the first-line fluid resuscitation solution to minimize the risk of hyperchloremic metabolic acidosis and acute kidney injury 1, 4
Normal saline (0.9% NaCl) should be avoided as it is associated with a higher incidence of acute kidney injury compared to balanced solutions 1, 2
Intravenous access should be obtained as soon as possible, preferably in unburned areas; if IV access cannot be rapidly obtained, an intraosseous route is recommended 1

After initial resuscitation, fluid requirements should be calculated using formulas such as the Parkland formula (2-4 mL/kg/%TBSA over the first 24 hours) 1, 5
For children, higher fluid volumes may be required (approximately 6 mL/kg/%TBSA in the first 48 hours) due to their higher body surface area/weight ratio 5, 6
Fluid administration should be adjusted based on clinical response, with urine output being a key parameter (target: 0.5-1 mL/kg/hour) 7, 6

Human albumin should be administered to severe burns patients with TBSA >30% after the first 6 hours of management 8, 9
Target albumin levels >30 g/L with doses generally around 1-2 g/kg/day 8, 10
Albumin administration can reduce the volume of crystalloids required, potentially decreasing complications related to fluid overload including congestive acute kidney injury 9, 10

Monitor for compartment syndrome, which can worsen AKI through increased intra-abdominal pressure 3, 4
Consider escharotomy for third-degree circumferential burns that cause constriction and increased compartmental pressure 3
Escharotomy should be performed at a Burns Center whenever possible; if transfer is not feasible, specialist advice should be obtained 2, 3

If hypotension persists despite appropriate fluid resuscitation, vasopressors can be used 7
Cardiac function and intravascular volume status should be evaluated using echocardiography or alternative hemodynamic monitoring 7
Protocol-based management of hemodynamic parameters is suggested to prevent development or worsening of AKI in high-risk patients 11

Provide 20-30 kcal/kg/day total energy intake in patients with AKI 11
Avoid protein restriction with the aim of preventing or delaying initiation of renal replacement therapy 11
Administer 0.8-1.0 g/kg/day of protein in noncatabolic AKI patients without need for dialysis, 1.0-1.5 g/kg/day in patients with AKI on RRT, and up to 1.7 g/kg/day in patients on continuous renal replacement therapy (CRRT) 11
Provide nutrition preferentially via the enteral route 11