title: Early implementation of continuous renal replacement therapy optimizes casualty evacuation for combat-related acute kidney injury.
abstract: BACKGROUND
  The purpose of this report was to review the initial use and feasibility of continuous renal replacement therapy (CRRT) among combat casualties in a war zone. Although rapid evacuation to more advanced levels of care has emerged as the standard approach, life-threatening sequelae of acute kidney injury (AKI) can preclude safe patient evacuation. For the first time in US combat casualty care, a sustained, intensivist-led CRRT program was initiated during 2010 at an Air Force theater hospital.
  
  
  METHODS
  A prospective study of consecutive US service members (USSMs) who developed combat-related renal failure and underwent CRRT at the Craig Joint Theater Hospital was undertaken. Baseline patient characteristics, indications for CRRT, laboratory values, and outcomes were evaluated.
  
  
  RESULTS
  Nine USSMs were treated during 14-months. All were male, with a mean (SD) age of 28 (7) years and mean (SD) Injury Severity Score (ISS) of 34 (12). The dominant mechanism was blast injury (8 of 9), followed by gunshot wound (1 of 9). Most patients were Acute Kidney Injury Network (AKIN) 3 and all developed critical hyperkalemia (mean [SD], peak K⁺ 6.4 [0.4]). The peak plasma creatinine ranged from 1.4 mg/dL to 4.2 mg/dL (mean [SD], 3.3 [0.9] mg/dL). Patients had a mean (SD) of 17.6 [8.1] hours of CRRT before evacuation to higher echelons of care. All USSMs survived to achieve safe evacuation from the combat zone to the regional trauma center in Landstuhl, Germany (Landstuhl Regional Medical Center). Three patients died of multiorgan failure at Landstuhl Regional Medical Center. Six patients survived to undergo additional treatment in the United States.
  
  
  CONCLUSIONS
  Intensivist-led CRRT is an effective therapeutic adjunct in the treatment of combat-related AKI. Provision of this extracorporeal therapy provides physiologic stabilization of casualties who might otherwise succumb to the sequelae of combat-related renal failure. These findings suggest that a self-sustaining CRRT program can be successfully implemented in combat support hospitals.
authors.affiliation: Department of Surgery, Landstuhl Regional Medical Center, Landstuhl, Germany. david.zonies2@us.af.mil
authors.forename: David
authors.initials: D
authors.lastname: Zonies
authors.forename: Joseph
authors.initials: J
authors.lastname: DuBose
authors.forename: Joel
authors.initials: J
authors.lastname: Elterman
authors.forename: Todd
authors.initials: T
authors.lastname: Bruno
authors.forename: Christian
authors.initials: C
authors.lastname: Benjamin
authors.forename: Jeremy
authors.initials: J
authors.lastname: Cannon
authors.forename: Kevin K
authors.initials: KK
authors.lastname: Chung
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology / Q000628:therapy*; D000328:Adult; D055826:Afghan Campaign 2001-; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008887:Military Medicine / Q000379:methods*; D011446:Prospective Studies; D017582:Renal Replacement Therapy / Q000379:methods*; D014187:Transportation of Patients / Q000379:methods; D014947:Wounds and Injuries / Q000150:complications* / Q000628:therapy; D055815:Young Adult