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Reciprocal Risk of Acute Kidney Injury and Acute Respiratory Distress Syndrome in Critically Ill Burn Patients*

Clemens, Michael S. MD; Stewart, Ian J. MD; Sosnov, Jonathan A. MD; Howard, Jeffrey T. PhD; Belenkiy, Slava M. MD; Sine, Christy R. MD; Henderson, Jonathan L. MD; Buel, Allison R. DO; Batchinsky, Andriy I. MD; Cancio, Leopoldo C. MD, FCCM; Chung, Kevin K. MD, FCCM

doi: 10.1097/CCM.0000000000001812
Online Clinical Investigations

Objective: To evaluate the association between acute respiratory distress syndrome and acute kidney injury with respect to their contributions to mortality in critically ill patients.

Design: Retrospective analysis of consecutive adult burn patients requiring mechanical ventilation.

Setting: A 16-bed burn ICU at tertiary military teaching hospital.

Patients: Adult patients more than 18 years old requiring mechanical ventilation during their initial admission to our burn ICU from January 1, 2003, to December 31, 2011.

Interventions: None.

Measurements and Main Results: A total 830 patients were included, of whom 48.2% had acute kidney injury (n = 400). These patients had a 73% increased risk of developing acute respiratory distress syndrome after controlling for age, gender, total body surface area burned, and inhalation injury (hazard ratio, 1.73; 95% CI, 1.18–2.54; p = 0.005). In a reciprocal multivariate analysis, acute respiratory distress syndrome (n = 299; 36%) demonstrated a strong trend toward developing acute kidney injury (hazard ratio, 1.39; 95% CI, 0.99–1.95; p = 0.05). There was a 24% overall in-hospital mortality (n = 198). After adjusting for the aforementioned confounders, both acute kidney injury (hazard ratio, 3.73; 95% CI, 2.39–5.82; p < 0.001) and acute respiratory distress syndrome (hazard ratio, 2.16; 95% CI, 1.58–2.94; p < 0.001) significantly contributed to mortality. Age, total body surface area burned, and inhalation injury were also significantly associated with increased mortality.

Conclusions: Acute kidney injury increases the risk of acute respiratory distress syndrome in mechanically ventilated burn patients, whereas acute respiratory distress syndrome similarly demonstrates a strong trend toward the development of acute kidney injury. Acute kidney injury and acute respiratory distress syndrome are both independent risks for subsequent death. Future research should look at this interplay for possible early interventions.

Supplemental Digital Content is available in the text.

1Department of Medicine, San Antonio Military Medical Center, Fort Sam Houston, TX.

2David Grant Medical Center, Clinical Investigation Facility, Travis Air Force Base, CA.

3Uniformed Services University of the Health Sciences, Bethesda, MD.

4Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX.

5Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, WV.

6Geneva Foundation, Tacoma, WA.

*See also p. 1950.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, the Department of the Air Force, or the Department of Defense.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Supported by the Clinical Trials Task Area, U.S. Army Institute of Surgical Research, Ft Sam Houston, TX. Supported, in part, by a postdoctoral fellowship provided by the Oak Ridge Institute of Science and Education.

Drs. Chung, Clemens, Stewart, Sosnov, Howard, Sine, Henderson, and Cancio disclosed government work. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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