Scand J Plast Reconstr Surg 13: 189-192, 1979
ACUTE RENAL FAILURE IN BURNS
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
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
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.
The principal causes of death in burns patients are respiratory failure, infection, metabolic abnormalities, myocardial failure and renal failure. The overall incidence of established Acute Renal Failure is low (Table I), although this may reflect underdiagnosis. 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 Failure 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 treated 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 electrical 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 reconstructive 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 function returned to normal. Several skin grafting operations were required, and he died two months later of septicaemia and hepatic failure. Cuse 3 A 36-year-old man sustained 52% flame burns involving the trunk, thighs and left arm. He was adequately 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
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
Birmingham (1953-1%5), Cason, 1%6 U.S. Army (1960-1966), Vertel & Knochel, 1967 Guys (1953-1%7), Cameron & Miller-Jones, 1%7 Roehampton (195!9-1966), Evans, 1969
Patients
A.R.F.
Survivors
3 690
49
9
I050
24
3
720 602
22 0
1 0
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 Age
burn
Aetiology
Treatment
Duration (days)
53
52
Flame
PD
31
12
Electric
PD/H
29 55 38 36
16 50 42 52
Electric Flame Flame Flame
PD HD HD HD
20 (oliguria) II (oliguria) 8
%
Case no.
17 4 20
Outcome
Commentlcause of death
Survived
Died 2 months later, hepatic failure Arm amputated
Survived Died Died Died Survived
(oliguria) 46 29 46 33 58 10 39 51 50 63
45 75 60 30 40 50 40 17 25 17
Flame Flame Flame Electric Flame Flame Flame Electric Flame Flame
HD PD PD/HD HD HD HD HD HD Cons. Cons.
7 3 17 53 65 22
65 50
Flame Flame Flame Electric Blast Electric/ flame Scald Flame Flame Flame Scald Flame
HD PD PD/HD HD HD HD
22 57 34 21 4Y
12
60 25 15 80 85 50
60 70 45 70
HD HD Cons. PD HD HD
non-oliguric Acute Renal Failure. Haemodialysis was started, but 2 days later gas gangrene of the left arm was diagnosed. Treatment with hyperbaric oxygen was started, and the limb amputated. Further eight daily treatments with hyperbaric oxygen resuited in the resolution of gas gangrene, and daily S c u d J Plus1 Reconstr Siirg I3
14 6 5 6 5 9 12 10 16 4
(oliguria) 7 3
6 2 6 8 6 5 ?
3 3 9
Died Died Died Died Died Died Died Died Died Survived Died Died Died Died Died Died Died Died Died Died Died Died
Arm amputated, pneumonia Pneumonia Pneumonia Arm amputated. hyperbaric 0, treatment, myocarditis Pneumonia Pneumonia Pneumonia Toxaemia, peritonitis Pneumonia, GI bleeding Toxaemia Septicaemia, pneumonia Arm amputated, pneumonia Septicaemia, peritonitis Arm and leg amputated, myocardit is Toxaemia Toxaemia ?
Multiple injuries Pneumonia, GI bleeding Arm amputated, toxaemia Septicaemia, pneumonia 'I
? ?
Septicaemia
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.
Acrrtr rrtialjuilrrrr in birrris
191
Table 111. Siirvivors of Jicr1ysi.s in brrrnrd pcrticwts H = haemodialysis, P = peritoneal dialysis Author
A.E.T.
Dialysis
Comment
1958 Alwall, N . 1960 Goldsmith 1965 Alwall, N .
Electric Flame Electric Flame ( 1 child, no details) Electric Electric Electric Electric Electric Flame
Hx3 Hx2 Hx3 Hx 1
Amputation
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
1%5 Stephens 1%7 Cameron 1%7 Dossetor 1971 Hartford 1971 Marshall
1973 Tagnor 1974 Settle
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 became oliguric despite fluid replacement, and had his right leg amputated two days later. His Acute Renal Failure was treated conservatively, and he improved slowly obtaining a diuresis after 2 weeks. He subsequently required amputation of the right arm, and recovered adequate renal function. He died four months after the burns of toxic myocarditis, confirmed at post-mortem. DISCUSSION Renal function is affected by several aspects of burns pathology, including hypovolaemia, lowered cardiac output, increased sympathetic activity, respiratory failure with hypoxia and acidosis, toxaemia and septicaemia (Eklund et al.). Most patients with severe burns have impaired renal function 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 disturbed electrolytes, have been described by Eklund and by Settle (Eklund, 1970b, c; Settle, 1974). They include: increased plasma creatinine and osmolality; decreased urine to plasma creatinine ratio; decreased creatinine clearance; increased ratio between 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 osmolality, the above indices can be follwed and earlier
HxS Hx7 Hx4 PX 14 (No details) Px 10
Amputation Amputation Amputation
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 cardiovascular 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 diminish chances of further infection. Survival of burns patients with Acute Renal Failure 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 Dosseter, 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.
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
(53%) or traumatic (50%) cases (Flynn, 1974). We believe that the gross metabolic disturbances, release of burn “toxins”, and high risk of severe infection, 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 massive 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 Failure following burns injury is presented. We believe that the extremely poor prognosis of these patients can be improved, and that they should not be denied treatment. Early diagnosis, prompt and adequate 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.
REFERENCES Alwall, N. 1965. Therapeutic and diagnostic problems in severe renal failure. Stockholm. Alwall, N. & Kjellstrand, C. M., 1958. D. Actura. Therapie der Nieren-Insufizienz. Dtsch Med Wochenschr 8 3 , 950.
Srund J Plost Recoristr Siirg 13
Bartlett, R. H., Gentile, D. E., Allyn, P. A.. Nittrd D. E. & Quasha, I. 1973. Haemodialysis in the management of massive burns. Trans Am Soc Arttflnt Organs. vol.
XIX. Cameron, J. S. & Miller-Jones, C. M. H. 1967. Renal function and renal failure in badly burned children. Br J Surg 54. 132. Cason, J. S. 1966. In Transactions of I I I n t Congress Res Burns, p. 12. Livingstone, Edinburgh. Dossetor, J. B.. Drummond, J. A., Allen, A. C., Celis, M. D. & Baxter, H. A . 1967. Prolonged oliguric renal failure after electric burns. Plast Reconsr Surg 40, 67. Eklund, J., Gronberg, P. 0. & Liljedahl, S. 0. 1 9 7 0 ~ . Studies on renal function in bums. I. Acrii Chir Srund 136, 627. Eklund, J., 19706. Studies on renal function in bums. 11. Acta Chir Scund 136, 735. - 1970c. Studies on renal function in bums. 111. Acta Chir Scand 136, 741. Evans, A. J. 1969. Bums in children. Proc Roy Soc Med 62, 50.
Flynn. C. T. 1%7. Peritoneal dialysis in hypercatabolic acute renal failure. Lancet I , 1331. - 1974. Treatment of acute renal failure. In Acute renal failure (ed. C . T. Flynn), p. 113. Medical and Technical Publishers, Lancaster. Goldsmith, H. G., Nakamoto. N. & Kolff, W. J. 1960. Expanding the indications for treatment with the artificial kidney. Lancer 2 , 1 I 1. Hartford, C. E. & Ziffren, S. E. 1971. Electrical injury. J Trauma I I , 331. Marshall, V. C. 1971. Acute renal failure in surgical patients. Br J Surg 58. 17. Parsons, F. M., Hosbon, S. M., Blagg, C. R. & McCracken, B. H. 1%1. Optimum time for dialysis in acute reversible renal failure. Lancet I , 129. Rainford, D. J. 1977. The immediate care of acute renal failure. Anaesthesia 32. 277. Settle, J. A. D. 1974. Urine output following severe burns. Burns I , 23. Stephens, F. 0. & Stewart, J. H. 1%5. Bums complicated by recovery after radical surgery and haemodialysis. Lancet2. 15.
Tagnar, A. 1973. Successful treatment of acute renal failure due to electric injury. Jap J Nephrol15. 427. Vertel, R. M. & Knochel, J. P. 1%7. Non-oliguric acute renal failure. J Am Med Ass 200. 598.
ACUTE RENAL FAILURE IN BURNS
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
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
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.
The principal causes of death in burns patients are respiratory failure, infection, metabolic abnormalities, myocardial failure and renal failure. The overall incidence of established Acute Renal Failure is low (Table I), although this may reflect underdiagnosis. 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 Failure 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 treated 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 electrical 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 reconstructive 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 function returned to normal. Several skin grafting operations were required, and he died two months later of septicaemia and hepatic failure. Cuse 3 A 36-year-old man sustained 52% flame burns involving the trunk, thighs and left arm. He was adequately 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
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
Birmingham (1953-1%5), Cason, 1%6 U.S. Army (1960-1966), Vertel & Knochel, 1967 Guys (1953-1%7), Cameron & Miller-Jones, 1%7 Roehampton (195!9-1966), Evans, 1969
Patients
A.R.F.
Survivors
3 690
49
9
I050
24
3
720 602
22 0
1 0
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 Age
burn
Aetiology
Treatment
Duration (days)
53
52
Flame
PD
31
12
Electric
PD/H
29 55 38 36
16 50 42 52
Electric Flame Flame Flame
PD HD HD HD
20 (oliguria) II (oliguria) 8
%
Case no.
17 4 20
Outcome
Commentlcause of death
Survived
Died 2 months later, hepatic failure Arm amputated
Survived Died Died Died Survived
(oliguria) 46 29 46 33 58 10 39 51 50 63
45 75 60 30 40 50 40 17 25 17
Flame Flame Flame Electric Flame Flame Flame Electric Flame Flame
HD PD PD/HD HD HD HD HD HD Cons. Cons.
7 3 17 53 65 22
65 50
Flame Flame Flame Electric Blast Electric/ flame Scald Flame Flame Flame Scald Flame
HD PD PD/HD HD HD HD
22 57 34 21 4Y
12
60 25 15 80 85 50
60 70 45 70
HD HD Cons. PD HD HD
non-oliguric Acute Renal Failure. Haemodialysis was started, but 2 days later gas gangrene of the left arm was diagnosed. Treatment with hyperbaric oxygen was started, and the limb amputated. Further eight daily treatments with hyperbaric oxygen resuited in the resolution of gas gangrene, and daily S c u d J Plus1 Reconstr Siirg I3
14 6 5 6 5 9 12 10 16 4
(oliguria) 7 3
6 2 6 8 6 5 ?
3 3 9
Died Died Died Died Died Died Died Died Died Survived Died Died Died Died Died Died Died Died Died Died Died Died
Arm amputated, pneumonia Pneumonia Pneumonia Arm amputated. hyperbaric 0, treatment, myocarditis Pneumonia Pneumonia Pneumonia Toxaemia, peritonitis Pneumonia, GI bleeding Toxaemia Septicaemia, pneumonia Arm amputated, pneumonia Septicaemia, peritonitis Arm and leg amputated, myocardit is Toxaemia Toxaemia ?
Multiple injuries Pneumonia, GI bleeding Arm amputated, toxaemia Septicaemia, pneumonia 'I
? ?
Septicaemia
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.
Acrrtr rrtialjuilrrrr in birrris
191
Table 111. Siirvivors of Jicr1ysi.s in brrrnrd pcrticwts H = haemodialysis, P = peritoneal dialysis Author
A.E.T.
Dialysis
Comment
1958 Alwall, N . 1960 Goldsmith 1965 Alwall, N .
Electric Flame Electric Flame ( 1 child, no details) Electric Electric Electric Electric Electric Flame
Hx3 Hx2 Hx3 Hx 1
Amputation
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
1%5 Stephens 1%7 Cameron 1%7 Dossetor 1971 Hartford 1971 Marshall
1973 Tagnor 1974 Settle
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 became oliguric despite fluid replacement, and had his right leg amputated two days later. His Acute Renal Failure was treated conservatively, and he improved slowly obtaining a diuresis after 2 weeks. He subsequently required amputation of the right arm, and recovered adequate renal function. He died four months after the burns of toxic myocarditis, confirmed at post-mortem. DISCUSSION Renal function is affected by several aspects of burns pathology, including hypovolaemia, lowered cardiac output, increased sympathetic activity, respiratory failure with hypoxia and acidosis, toxaemia and septicaemia (Eklund et al.). Most patients with severe burns have impaired renal function 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 disturbed electrolytes, have been described by Eklund and by Settle (Eklund, 1970b, c; Settle, 1974). They include: increased plasma creatinine and osmolality; decreased urine to plasma creatinine ratio; decreased creatinine clearance; increased ratio between 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 osmolality, the above indices can be follwed and earlier
HxS Hx7 Hx4 PX 14 (No details) Px 10
Amputation Amputation Amputation
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 cardiovascular 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 diminish chances of further infection. Survival of burns patients with Acute Renal Failure 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 Dosseter, 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.
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
(53%) or traumatic (50%) cases (Flynn, 1974). We believe that the gross metabolic disturbances, release of burn “toxins”, and high risk of severe infection, 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 massive 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 Failure following burns injury is presented. We believe that the extremely poor prognosis of these patients can be improved, and that they should not be denied treatment. Early diagnosis, prompt and adequate 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.
REFERENCES Alwall, N. 1965. Therapeutic and diagnostic problems in severe renal failure. Stockholm. Alwall, N. & Kjellstrand, C. M., 1958. D. Actura. Therapie der Nieren-Insufizienz. Dtsch Med Wochenschr 8 3 , 950.
Srund J Plost Recoristr Siirg 13
Bartlett, R. H., Gentile, D. E., Allyn, P. A.. Nittrd D. E. & Quasha, I. 1973. Haemodialysis in the management of massive burns. Trans Am Soc Arttflnt Organs. vol.
XIX. Cameron, J. S. & Miller-Jones, C. M. H. 1967. Renal function and renal failure in badly burned children. Br J Surg 54. 132. Cason, J. S. 1966. In Transactions of I I I n t Congress Res Burns, p. 12. Livingstone, Edinburgh. Dossetor, J. B.. Drummond, J. A., Allen, A. C., Celis, M. D. & Baxter, H. A . 1967. Prolonged oliguric renal failure after electric burns. Plast Reconsr Surg 40, 67. Eklund, J., Gronberg, P. 0. & Liljedahl, S. 0. 1 9 7 0 ~ . Studies on renal function in bums. I. Acrii Chir Srund 136, 627. Eklund, J., 19706. Studies on renal function in bums. 11. Acta Chir Scund 136, 735. - 1970c. Studies on renal function in bums. 111. Acta Chir Scand 136, 741. Evans, A. J. 1969. Bums in children. Proc Roy Soc Med 62, 50.
Flynn. C. T. 1%7. Peritoneal dialysis in hypercatabolic acute renal failure. Lancet I , 1331. - 1974. Treatment of acute renal failure. In Acute renal failure (ed. C . T. Flynn), p. 113. Medical and Technical Publishers, Lancaster. Goldsmith, H. G., Nakamoto. N. & Kolff, W. J. 1960. Expanding the indications for treatment with the artificial kidney. Lancer 2 , 1 I 1. Hartford, C. E. & Ziffren, S. E. 1971. Electrical injury. J Trauma I I , 331. Marshall, V. C. 1971. Acute renal failure in surgical patients. Br J Surg 58. 17. Parsons, F. M., Hosbon, S. M., Blagg, C. R. & McCracken, B. H. 1%1. Optimum time for dialysis in acute reversible renal failure. Lancet I , 129. Rainford, D. J. 1977. The immediate care of acute renal failure. Anaesthesia 32. 277. Settle, J. A. D. 1974. Urine output following severe burns. Burns I , 23. Stephens, F. 0. & Stewart, J. H. 1%5. Bums complicated by recovery after radical surgery and haemodialysis. Lancet2. 15.
Tagnar, A. 1973. Successful treatment of acute renal failure due to electric injury. Jap J Nephrol15. 427. Vertel, R. M. & Knochel, J. P. 1%7. Non-oliguric acute renal failure. J Am Med Ass 200. 598.
