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Proenkephalin A 119-159 (penKid) has been proposed as a sensitive biomarker of renal function. This study evaluated the association of concentrations of plasma penKid with death and risk of acute kidney injury (AKI) in severely ill burn patients.A prospective observational study in two centers with severely ill adult burn patients was conducted. The inclusion criteria were total body surface area (TBSA) burns15%, with burn injury occurring72 h before intensive care unit (ICU) admission and plasma sample taken at admission. The primary endpoint was 90-day mortality. The secondary endpoints were AKI and a combined endpoint of 90-day mortality and/or AKI. Mortality was also evaluated in the sub-group of patients with sub-clinical AKI, defined as a patient without AKI but with elevated penKid.A total of 113 consecutive patients were enrolled. The median age was 48 years (Interquartile range [IQR] 33-64), the median burn TBSA was 35% (IQR 25-53), and 90-day mortality was 31.9%. Thirty-one percent of the patients had AKI, and 41.6% of patients had the combined endpoint. There was a stepwise decrease in survival from patients without AKI, sub-AKI, and with AKI (survival rate 90.0% [95% CI 82.7-97.9], 66.7% [95% CI 48.1-92.4], and 31.4% [95% CI 19.3-51.3], respectively, p0.001). Plasma penKid concentration was significantly higher in non-survivors compared to survivors (86.9 pmol/L [IQR 53.3-166.1] versus 52.9 pmol/L [IQR 37.1-70.7]; p = 0.0001) and in patients with AKI compared to patients without AKI (86.4 pmol/L [IQR 56.5-153.4] versus 52.5 pmol/L [IQR 35.5-71.2]; p0.001). Penkid provided added value on top of serum creatinine (Screat) and Sepsis Related Organ Failure Assessment (SOFA) scores to predict 90-day mortality (combined c-index of 0.738 versus 0.707; p = 0.024 and 0.787 versus 0.752; p0.001).Plasma penKid concentration at admission was associated with an increased risk of death in burn patients. PenKid has additional prognostic value on top of Screat and SOFA to predict 90-day mortality.

Background Dipeptidyl peptidase-3 (DPP3) is a metallopeptidase which cleaves bioactive peptides, notably angiotensin II, and is involved in inflammation regulation. DPP3 has been proposed to be a myocardial depressant factor and to be involved in circulatory failure in acute illnesses, possibly due to angiotensin II cleavage. In this study, we evaluated the association between plasmatic DPP3 level and outcome (mortality and hemodynamic failure) in severely ill burn patients. Methods In this biomarker analysis of a prospective cohort study, we included severely ill adult burn patients in two tertiary burn intensive care units. DPP3 was measured at admission (DPP3admin) and 3 days after. The primary endpoint was 90-day mortality. Secondary endpoints were hemodynamic failure and acute kidney injury (AKI). Results One hundred and eleven consecutive patients were enrolled. The median age was 48 (32.5–63) years, with a median total body surface area burned of 35% (25–53.5) and Abbreviated Burn Severity Index (ABSI) of 8 (7–11). Ninety-day mortality was 32%. The median DPP3admin was significantly higher in non-survivors versus survivors (53.3 ng/mL [IQR 28.8–103.5] versus 27.1 ng/mL [IQR 19.4–38.9]; p admin but decreased levels on day 3. Patients with circulatory failure had higher DPP3admin (39.2 ng/mL [IQR 25.9–76.1] versus 28.4 ng/mL [IQR 19.8–39.6]; p = 0.001) as well as patients with AKI (49.7 ng/mL [IQR 30.3–87.3] versus 27.6 ng/mL [IQR 19.4–41.4]; p = 0.001). DPP3admin added prognostic value on top of ABSI (added chi2 12.2, p = 0.0005), Sequential Organ Failure Assessment (SOFA) score at admission (added chi2 4.9, p = 0.0268), and plasma lactate at admission (added chi2 6.9, p = 0.0086) to predict circulatory failure within the first 48 h. Conclusions Plasma DPP3 concentration at admission was associated with an increased risk of death, circulatory failure, and AKI in severely burned patients. Whether DPP3 plasma levels could identify patients who would respond to alternative hemodynamic support strategies, such as intravenous angiotensin II, should be explored.

Introduction Les patients presentant une surface cutanee brulee (SCB) superieure a 50 % sont rares mais leur prise en charge constitue un defi pour les centres de traitement des brules. La survie et la duree de sejour de tels patients sont des marqueurs simples de la qualite des soins. Nous avons donc etudie la morbi-mortalite des patients severement brules de notre service, ainsi que la pertinence des scores pronostiques utilises au quotidien. Materiel et methodes Il s’agit d’une etude retrospective monocentrique realisee dans le centre de traitement des brules Universitaire de Lyon portant sur tous les patients admis pour une brulure couvrant plus de 50 % de surface corporelle, de janvier 2000 a decembre 2014. Les donnees demographiques, l’IGS2, les causes de deces, les complications durant le sejour, et des facteurs pronostiques specifiques du patient brule (l’index de Baux (IB) et l’Abbreviated Burns Severity Index (ABSI)) ont ete recueillis. Les patients ont ete separes en 2 groupes (« vivants », et « decedes »), et compares selon les tests du Chi-2, et U de Mann et Whitney, avec une significativite pour des valeurs de p Resultats Sur la periode etudiee de 15 ans, 164 patients ont ete inclus, dont 74 % d’hommes et 35 % apres une tentative d’autolyse. L’Index de Baux median est de 115 [92–132], la mediane de l’ABSI est a 12 [10–13], et 70 (42 %) des patients presentent des lesions respiratoires par inhalation. Soixante-treize patients sont decedes (44 %). Parmi eux, 15 (20 %) sont decedes dans les 48 premieres heures. Concernant la mortalite precoce (avant 48 h), celle-ci est en grande partie liee a la survenue d’une defaillance multi-viscerale (60 % cas), ou d’un SDRA (35 %). Les complications infectieuses ( n = 71 ; 42 %) sont les plus frequentes apres 48 heures. Les principaux facteurs pronostics identifies sont : l’âge et les scores pronostiques de reanimation ou specifiques des brules ( Tableau 1 ). La duree mediane de sejour chez les survivants est de 72 [54–99] jours. Les principales complications infectieuses sont les pneumopathies acquises sous ventilation mecanique, retrouvees chez 63 % des patients, precoces ( Discussion La mortalite observee dans notre centre ainsi que la duree mediane de sejour sont comparables aux donnees rapportees par les autres centres de traitement des brules des pays industrialises [1] . L’âge et le pourcentage de SCB sont consideres comme les scores pronostiques les plus importants [2] , ce qui est retrouve par notre etude. Nous retrouvons egalement la pertinence des scores pronostiques specifiques des brules, ce qui suggere qu’ils pourraient etre utilises comme outils de stratification therapeutiques.

Von Willebrand disease (VWD) is a common inherited bleeding disorder. Its diagnosis is based on the association of bleeding symptoms and specific biological data [1,2]. The cornerstone of its treatment is the replacement of the deficient protein during acute spontaneous bleeding episodes or before invasive procedures. It may induce haemorrhagic morbidities in severe burn since the coagulation homeostasis is frequently impaired by itself in that setting and since excision and closure of burn wound are regularly required in such patients. However, the specific management of patients with both severe burn and type 2A VWD has not yet been described. We therefore report a paediatric case of type 2A VWD admitted for severe burn.

Background Although multiple individual immune parameters have been demonstrated to predict the occurrence of secondary infection after critical illness, significant questions remain with regards to the selection, timing and clinical utility of such immune monitoring tests. Research question As a sub-study of the REALISM study, the REALIST score was developed as a pragmatic approach to help clinicians better identify and stratify patients at high risk for secondary infection, using a simple set of relatively available and technically robust biomarkers. Study design and methods This is a sub-study of a single-centre prospective cohort study of immune profiling in critically ill adults admitted after severe trauma, major surgery or sepsis/septic shock. For the REALIST score, five immune parameters were pre-emptively selected based on their clinical applicability and technical robustness. Predictive power of different parameters and combinations of parameters was assessed. The main outcome of interest was the occurrence of secondary infection within 30 days. Results After excluding statistically redundant and poorly predictive parameters, three parameters remained in the REALIST score: mHLA-DR, percentage of immature (CD10− CD16−) neutrophils and serum IL-10 level. In the cohort of interest (n = 189), incidence of secondary infection at day 30 increased from 8% for patients with REALIST score of 0 to 46% in patients with a score of 3 abnormal parameters, measured ad D5–7. When adjusted for a priori identified clinical risk factors for secondary infection (SOFA score and invasive mechanical ventilation at D5–7), a higher REALIST score was independently associated with increased risk of secondary infection (42 events (22.2%), adjusted HR 3.22 (1.09–9.50), p = 0.034) and mortality (10 events (5.3%), p = 0.001). Interpretation We derived and presented the REALIST score, a simple and pragmatic stratification strategy which provides clinicians with a clear assessment of the immune status of their patients. This new tool could help optimize care of these individuals and could contribute in designing future trials of immune stimulation strategies. Graphical Abstract