Early application of continuous high-volume haemofiltration can reduce sepsis and improve the prognosis of patients with severe burns

Abstract

BackgroundIn the early stage of severe burn, patients often exhibit a high level of inflammatory mediators in blood and are likely to develop sepsis. High-volume haemofiltration (HVHF) can eliminate these inflammatory mediators. We hypothesised that early application of HVHF may be beneficial in reducing sepsis and improving the prognosis of patients with severe burns.MethodsAdults patients with burns ≥ 50% total burn surface area (TBSA) and in whom the sum of deep partial and full-thickness burn areas was ≥ 30% were enrolled in this randomised prospective study, and they were divided into control (41 cases) and HVHF (41 cases) groups. Patients in the control group received standard management for major burns, whereas the HVHF group additionally received HVHF treatment (65 ml/kg/h for 3 consecutive days) within 3 days after burn. The incidence of sepsis and mortality, some laboratory data, levels of inflammatory cytokines in the blood, HLA-DR expression on CD14+ peripheral blood monocytes, the proportion of CD25+Foxp3+ in CD4+ T lymphocytes, and the counts of CD3+, CD4+ and CD8+ T lymphocytes were recorded within 28 days post-burn.ResultsThe incidence of sepsis, septic shock and duration of vasopressor treatment were decreased significantly in the HVHF group. In addition, in the subgroup of patients with burns ≥ 80% TBSA, the 90-day mortality showed significant decreases in the HVHF group. The ratio of arterial oxygen partial pressure to the fraction of inspiration oxygen was improved after HVHF treatment. In the patients who received HVHF treatment, the blood levels of inflammatory cytokines, including tumour necrosis factor-α, interleukin (IL)-1β, IL-6 and IL-8, as well as the blood level of procalcitonin were found to be lower than in the control group. Moreover, higher HLA-DR expression on CD14+ monocytes and a lower proportion of CD25+Foxp3+ in CD4+ T lymphocytes were observed in the patients in the HVHF group.ConclusionsEarly application of HVHF benefits patients with severe burns, especially for those with a greater burn area (≥ 80% TBSA), decreasing the incidence of sepsis and mortality. This effect may be attributed to its early clearance of inflammatory mediators and the recovery of the patient’s immune status.Trial registrationChinese Clinical Trial Register, ChiCTR-TRC-12002616. Registered on 24 October 2012.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2095-9) contains supplementary material, which is available to authorized users.

Renal Replacement Therapy for Burn Patients: A Systematic Review and Meta-Analysis

“…Two RCT studies did not nd that CRRT had a positive effect on the mortality of burn patients (51, 52). You 2018 (10) found that early HVHF treatment may reduce 90-day mortality of patients with severe burns (≥ 80% TBSA) (P = 0.049). A meta-analysis of these three RCT studies also did not show that CRRT could reduce the risk of death in burn patients with AKI compared with the standard care (non-RRT) (RR = 0.64, 95%CI 0.40-1.03, P = 0.06; Fig.…”

“…Three RCT studies compared the effects of standard care (non-RRT) and CRRT on patients' prognosis (10,51,52). Two RCT studies did not nd that CRRT had a positive effect on the mortality of burn patients (51, 52).…”

“…You 2018 found that administration of HVHF within 3 days after admission may reduce the 90-day mortality of patients with large-area severe burns (≥ 80% TBSA) (P = 0.049). This RCT study excluded burn patients with sepsis or multiple organ failure on admission (10). Early (0-3 days after injury) burn AKI is typically due to hypovolemia, poor renal perfusion, direct cardiac suppression from TNF-alpha, and precipitation of denatured proteins (79).…”

“…They concluded that HVHF was effective in reversing shock and improving organ function in burn patients with septic shock and AKI, but the data were insu cient to comment on improving survival (9). Another random prospective study concluded that HVHF conducted in the early stage (within 3 days) could reduce the incidence of sepsis and the mortality of patients with severe burns (10). Yoon 2017-burns found that early or late continuous renal replacement therapy (CRRT) did not change the prognosis of burn patients with AKI.…”

Early versus late initiation of renal replacement therapy impacts mortality in septic patients with acute kidney injury: a meta-analysis

“…Acute kidney injury associated with sepsis has a distinct pathophysiology [7], and septic patients with AKI may have a different response to renal replacement therapy (RRT) than those patients without sepsis [8,9]. RRT is known to improve the survival rate of patients with AKI in ICU, because it rectifies metabolic acidosis by removing lactate, regulating unmeasured anions and adjusting levels of phosphate and chloride [10,11]. It is widely consentient that if there are lifethreatening complications for septic patients with AKI, such as hyperkalemia, metabolic acidosis and acute pulmonary edema, RRT should be started immediately [5,[12][13][14][15].…”