Impact of the Great Eastern Japan Earthquake on Transplant Renal Function in Iwaki City, Fukushima

Disasters and kidney care: pitfalls and solutions

Patients with kidney disease, especially those with kidney failure, are particularly susceptible to the adverse effects of disasters because their survival depends on functional infrastructure, advanced technology, the availability of specific drugs and well-trained medical personnel. The risk of poor outcomes across the entire spectrum of patients with kidney diseases (acute kidney injury, chronic kidney disease and kidney failure on dialysis or with a functioning transplant) increases as a result of disaster-related logistical challenges. Patients who are displaced face even more complex problems owing to additional threats that arise during travel and after reaching their new location. Overall, risks may be mitigated by pre-disaster preparedness and training. Emergency kidney disaster responses depend on the type and severity of the disaster and include medical and/or surgical treatment of injuries, treatment of mental health conditions, appropriate diet and logistical interventions. After a disaster, patients should be evaluated for problems that were not detected during the event, including those that may have developed as a result of the disaster. A retrospective review of the disaster response is vital to prevent future mistakes. Important ethical concerns include fair distribution of limited resources and limiting harm. Patients with kidney disease, their care-givers, health-care providers and authorities should be trained to respond to the medical and logistical problems that occur during disasters to improve outcomes.

Lessons learned during the war in Ukraine: a report from the Renal Disaster Relief Task Force of the ERA

People living with kidney disease are among the most vulnerable at times of natural or man-made disasters. In addition to their unpredictable course, armed conflicts impose a major threat given the disruption of infrastructure, sanitation and access to food, water and medical care. The ongoing war in Ukraine has once more demonstrated the importance of preparedness, organization, coordination and solidarity during disasters. People living with kidney disease face serious challenges given their dependence on life-sustaining treatment, irrespective of whether they remain in the war zone or are displaced internally or externally. This especially affects those requiring kidney replacement therapy, dialysis or transplantation, but also patients with other kidney diseases and the medical staff who care for them. Soon after the war started, the European Renal Association assigned a Renal Disaster Relief Task Force dedicated to support the people living with kidney disease and the nephrology community in Ukraine. This report summarizes the major challenges faced, actions taken and lessons learned by this task force. We anticipate that the experience will help to increase preparedness and mitigate the devastating effects of armed conflicts on the kidney community in the future and propose to establish an international collaboration to extend this effort to other parts of the world facing similar challenges.

Kidney transplantation during mass disasters - from COVID-19 to other catastrophes A Consensus Statement by the DESCARTES Working Group and Ethics Committee of the ERA

Mass disasters are characterized by a disparity between health care demand and supply, which hampers complex therapies like kidney transplantation. Considering scarcity of publications on previous disasters, we reviewed transplantation practice during the recent COVID-19 pandemic, and dwelled upon this experience for guiding transplantation strategies in the future pandemic and non-pandemic catastrophes. We strongly suggest continuing transplantation programs during mass disasters, if medical and logistic operational circumstances are appropriate. Postponing transplantations from living donors and referral of urgent cases to safe regions or hospitals are justified. Specific preventative measures in anticipated disasters (such as vaccination programs during pandemics or evacuation in case of hurricanes or wars) may be useful to minimize risks. Immunosuppressive therapies should consider stratifying risk status and avoiding heavy immune suppression in patients with a low probability of therapeutic success. Discharging patients at the earliest convenience is justified during pandemics, whereas delaying discharge is reasonable in other disasters, if infrastructural damage results in unhygienic living environments for the patients. In the outpatient setting, telemedicine is a useful approach to reduce the patient load to hospitals, to minimize the risk of nosocomial transmission in pandemics and the need for transport in destructive disasters. If it comes down to save as many lives as possible, some ethical principles may vary in function of disaster circumstances, but elementary ethical rules are non-negotiable. Patient education is essential to minimize disaster-related complications and to allow for an efficient use of health care resources.

Armed conflicts and kidney patients: a consensus statement from the Renal Disaster Relief Task Force of the ERA

During conflicts, people with kidney disease, either those remaining in the affected zones or those who are displaced, may be exposed to additional threats because of medical and logistical challenges. Acute kidney injury developing on the battlefield, in field hospitals or in higher-level hospital settings is characterized by poor outcomes. People with chronic kidney disease may experience treatment interruptions, contributing to worsening kidney function. Patients living on dialysis or with a functioning graft may experience limitations of dialysis possibilities or availability of immunosuppressive medications, increasing the risk of severe complications including death. When patients must flee, these threats are compounded by unhealthy and insecure conditions both during displacement and/or at their destination. Measures to attenuate these risks may only be partially effective. Local preparedness for overall and medical/kidney-related disaster response is essential. Due to limitations in supply, adjustments in dialysis frequency or dose, switching between hemodialysis and peritoneal dialysis and changes in immunosuppressive regimens may be required. Telemedicine (if possible) may be useful to support inexperienced local physicians in managing medical and logistical challenges. Limited treatment possibilities during warfare may necessitate referral of patients to distant higher-level hospitals, once urgent care has been initiated. Preparation for disasters should occur ahead of time. Inclusion of disaster nephrology in medical and nursing curricula and training of patients, families and others on self-care and medical practice in austere settings may enhance awareness and preparedness, support best practices adapted to the demanding circumstances and prepare non-professionals to lend support.

Recommendations of the Ukrainian Renal Disaster Relief Committee of the Ukrainian Association of Nephrologists and Kidney Transplant Specialists regarding medical care to kidney disease patients during the war

Abstract. The occurrence of an emergency situation (ES) forced international (ISN, EDTA/ERA) and national (Turkey) nephrological associations to establish the Renal Disaster Relief Task Force, which is primarily concerned with the treatment of patients with acute kidney injury and end-stage renal disease requiring dialysis. The war started by the RF is putting the Ukrainian state, Ukrainian society, and the healthcare system in the catastrophic ES. Under these circumstances, all nephrological patients became one of the most vulnerable categories of patients. To provide immediate support in solving problems within the Ukrainian Association of Nephrologists and Kidney Transplant Specialists (UAN&KTS), the Ukrainian Renal Disaster Relief Committee (URDRC) has been established. One of the most important tasks was to form a group of experts to develop recommendations for specialized medical care for kidney patients in wartime.  According to the experts, the key person for this type of medical care is the leading nephrologist in the region or city. He/she establishes a local Renal Disaster Relief Committee (LRDRC) and decides through horizontal (with other LRDRC) or vertical (with UAN &KTS) collaboration, using available communication tools, on the problems that arise; the most appropriate tool is the Viber platform "Nephrology. Dialysis. Transplantation". In this way, a network without administrative subordination and a non-hierarchical functional system was created, which, on the one hand, functions according to similar working principles, but, on the other hand, may differ in terms of LRDRC composition, communication methods, and more. The LRDRC divides all patients into three groups and provides work preparation measures before, during and after the cancellation of ES.

Disasters, children and the kidneys

Following disasters, children are physically, psychologically and socially more vulnerable than adults; consequently, their morbidity and mortality are higher. The risks are especially high for orphans and unaccompanied children who are separated from their families, making them frequently victims of human trafficking, slavery, drug addiction, crime or sexual exploitation. Education of children and families about disaster-related risks and providing special protection in disaster preparedness plans may mitigate these threats. Kidney disease patients, both paediatric and adult, are extra vulnerable during disasters, because their treatment is dependent on technology and functioning infrastructure. Acute kidney injury, chronic kidney disease patients not on dialysis and dialysis and transplant patients are faced with extensive problems. Overall, similar treatment principles apply both for adults and paediatric kidney patients, but management of children is more problematic, because of substantial medical and logistic difficulties. To minimize drawbacks, it is vital to be prepared for renal disasters. Preparedness plans should address not only medical professionals, but also patients and their families. If problems cannot be coped with locally, calling for national and/or international help is mandatory. This paper describes the spectrum of disaster-related problems in children and the specific features in treating acute and chronic kidney disease in disasters.