Renal Disaster Relief Task Force Research Articles

Distribution, preparedness and management of Ukrainian adult refugees on dialysis-an international survey by the Renal Disaster Relief Task Force of the European Renal Association.

Due to the Russian-Ukrainian war, some of the about 10 000 adults requiring dialysis in Ukraine fled their country to continue dialysis abroad. To better understand the needs of conflict-affected dialysis patients, the Renal Disaster Relief Task Force of the European Renal Association conducted a survey on distribution, preparedness and management of adults requiring dialysis who were displaced due to the war. A cross-sectional online survey was sent via National Nephrology Societies across Europe and disseminated to their dialysis centers. Fresenius Medical Care shared a set of aggregated data. Data were received on 602 patients dialyzed in 24 countries. Most patients were dialyzed in Poland (45.0%), followed by Slovakia (18.1%), Czech Republic (7.8%) and Romania (6.3%). The interval between last dialysis and the first in the reporting center was 3.1±1.6 days, but was ≥4 days in 28.1% of patients. Mean age was 48.1±13.4 years, 43.5% were females. Medical records were carried by 63.9% of patients, 63.3% carried a list of medications, 60.4% carried the medications themselves and 44.0% carried their dialysis prescription, with 26.1% carrying all of these items and 16.1% carrying none. Upon presentation outside Ukraine, 33.9% of patients needed hospitalization. Dialysis therapy was not continued in the reporting center by 28.2% of patients until the end of the observation period. We received information about approximately 6% of Ukrainian dialysis patients, who had fled their country by the end of August 2022. A substantial proportion were temporarily underdialyzed, carried incomplete medical information and needed hospitalization. The results of our survey may help to inform policies and targeted interventions to respond to the special needs of this vulnerable population during wars and other disasters in the future.

#5866 CLINICAL CHARACTERISTICS AND TREATMENT OF ADULT DIALYSIS PATIENTS FROM UKRAINE DISPLACED TO OTHER EUROPEAN COUNTRIES AFTER THE RUSSIAN INVASION

Abstract Background and Aims The Russian invasion on Ukraine, which started on 24th February 2022 led to migration of millions of people, including some of the about 10,000 adult dialysis patients. A Renal Disaster Relief Task Force (RDRTF) established by the European Renal Association, is dedicated to support the people living with kidney disease and to the nephrology community in Ukraine, working together with WHO, NGOs and industry. Besides these activities, the RDRTF conducted a survey to understand distribution and management of Ukrainian refugees requiring dialysis displaced to other European countries. The study aim was to characterize these patients and evaluate treatment modality and care they received after displacement. Method A cross-sectional online survey on status of displaced dialysis patients, clinical data and care they received after migration was sent to all national nephrology societies across Europe with a request to disseminate it to all dialysis centers in their countries. Data were collected between May and August 2022. Fresenius Medical Care (FMC) shared a set of aggregated data without direct center participation. Results Data on 602 patients (290 collected through the survey and 312 from FMC), who were dialyzed in 24 countries was gathered. Most patients were dialyzed in Poland (45.0%), followed by Slovakia (18.1%), Czech Republic (7.8%), Romania (6.3%), Germany (4.7%) and Hungary (3.5%). Mean time between last dialysis session and the first session in the reporting center was 3.1±1.6 days. For 28.1% of patients this time interval ranged from 4 to 12 days. Mean age was 48.1±13.4 years, and 43.5% of patients were females. The most common primary cause of kidney failure in the study group was glomerulonephritis or autoimmune diseases (29.5%), diabetic nephropathy constituted 12.7%. Before patients left Ukraine, 95.7% had been on hemodialysis, 2.5% on continuous ambulatory peritoneal dialysis (PD) and 1.8% on automated PD. Since leaving Ukraine, 33.8% of patients were hospitalized upon arrival at the reporting center. The most common causes of hospitalization were: anemia (18.6%), COVID-19 pneumonia (4.7%), non-COVID pneumonia (4.7%), overhydration (4.7%) and Perm-Cath implantation (4.7%), followed by exacerbation of heart failure, peripheral artery occlusive disease and arteriovenous fistula surgery. In terms of pharmacotherapy provided in the reporting dialysis units, 50.3% of patients received erythropoiesis stimulating agents and 36.9% received intravenous iron supplementation. 35.0%, 21.9% and 3.3% received phosphate binders, vitamin D analogues and cinacalcet, respectively. 29 patients (11.4%) were waitlisted for kidney transplantation (KTx) in Ukraine before displacement. Of these, 15 also qualified for KTx in the receiving country. A further 33 individuals who had not been listed for KTx in Ukraine, started the KTx recipient work-up under the care of the reporting center. Overall, 43 patients (17.4%) received psychological support – for 29 provided by the reporting dialysis units and for 14 patients outside the center. Conclusion Under 10% of dialysis patients fled Ukraine since the start of the Russian-Ukrainian war. Almost 30% of them remained without dialysis for 4 days or longer. Clinical status upon arrival often necessitated hospitalization. Our data indicate, that the treatment at receiving centers conformed with standard of care. Monitoring the situation of dialysis patients during armed conflicts may help in creating informed policies that allow for prompt and targeted interventions to respond to special needs of this vulnerable population.

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.

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.

Specialized medical care for chronic kidney disease patients during the war in Ukraine

Russian invasion is an unprecedented test for the Ukrainian state, Ukrainian society, and the health care system.
 According to the Ministry of Health of Ukraine, more than 600 healthcare facilities suffered serious damage (more than 100 hospitals and 450 pharmacies were ruined, and more than 200 emergency medical vehicles were destroyed).
 Patients with chronic diseases in the occupied territories and war zones are deprived of medical care and support, which is a direct threat to their lives.
 Chronic kidney disease (CKD) patients are one of the most vulnerable groups. Before the war, almost 10,000 patients were treated with dialysis kidney replacement therapy (KRT) and more than 1,500 had a functioning renal graft in Ukraine. The vast majority of patients with end-stage kidney disease receiving dialysis treatment were evacuated to safer regions, and some of them continued the treatment abroad. However, the war will significantly increase the number of patients in need of kidney care. In addition to the existing number of CKD patients, there will be a large group of patients with acute kidney injury (AKI) as a result of polytrauma, bleeding, injuries, or long-term compression syndrome. Currently, we cannot predict the incidence of AKI. However, according to the previously published data (18% - 34.6% of war victims), we should expect a significant increase in the population of CKD patients shortly which will require immediate changes in both organization and staffing of nephrology care.
 The medical community recognizes the insurmountable difficulties in providing medical support to Ukrainian citizens during the war, in particular patients receiving KRT or kidney recipients. In our opinion, special programs should be created by relevant professional associations together with the institutes of the Ministry of Health of Ukraine and the National Academy of Medical Sciences of Ukraine at both the state and regional levels in all areas.
 Therefore, we consider it extremely important to establish a committee for the organization of the healthcare system for CKD patients during wartime. The committee could be created within the Ukrainian Association of Nephrologists and Kidney Transplantation Specialists, for example, as the Renal Disaster Relief Task Force established by the International Association of Nephrologists. The main tasks of the committee are to create a consensus of the Ukrainian Association of Nephrologists and Kidney Transplantation Specialists on the management of CKD patients and patients with AKI during the war and the post-war period.
 On behalf of the Editorial Board of the Ukrainian Journal of Nephrology and Dialysis, we would like to express our sincere gratitude to all health professionals who, at the risk of their own lives, continue to save patients. All members of the Ukrainian nephrological community are doing everything possible and impossible to ensure the most adequate treatment of kidney patients in wartime. Thank you again.
 We pray for our heroic warriors who fearlessly defend us and defend Ukraine's independence!
 
 Slava Ukraini! Heroiam slava!

International Conference: "Renal Aspects of Disaster Relief", Ohrid, R. Macedonia, May 24-26, 1996.

The International Conference Renal Aspects of Disaster Relief, Ohrid, R. Macedonia, May 24-26, 1996 united doctors and engineers in order to better build settlements, and in case of an earthquake, how to help the injured.Plans have been proposed for the treatment of the injured with fluid and dialysis, as well as how to organize the non-governmental organizations and the population to assist the medical staff in optimizing the treatment of the injured.Members of the Renal Disaster Relief Task Force of the International Society of Nephrology and the European Renal Best Practice were tasked with preparing guidelines for medical staff and the population to address earthquake injuries.

Wars, disasters and kidneys

This paper summarizes the impact that wars had on the history of nephrology, both worldwide and in the Ghent Medical Faculty notably on the definition, research and clinical aspects of acute kidney injury. The paper briefly describes the role of ‘trench nephritis’� as observed both during World War I and II, supporting the hypothesis that many of the clinical cases could have been due to Hantavirus nephropathy. The lessons learned from the experience with crush syndrome first observed in World War II and subsequently investigated over many decades form the basis for the creation of the Renal Disaster Relief Task Force of the International Society of Nephrology. Over the last 15 years, this Task Force has successfully intervened both in the prevention and management of crush syndrome in numerous disaster situations like major earthquakes.

Raymond Vanholder: a titan of uraemic toxicity

Raymond Vanholder: a titan of uraemic toxicity

Management of Crush Victims in Mass Disasters

Crush syndrome is the second most common cause of death after earthquakes (the first most common is direct trauma). Many logistic problems with the treatment of patients with crush syndrome are due to chaotic disaster circumstances; consequently, medical and logistic recommendations on the treatment of crush victims are needed. In a joint initiative of the Renal Disaster Relief Task Force of the International Society of Nephrology and European Renal Best Practice, a work group of nephrologists, intensivists, surgeons, and logisticians with disaster experience or experts in guideline preparation collaborated to provide comprehensive information and recommendations on the management of crush casualties considering their occurrence with "epidemic" dimensions after mass disasters. The result is the monograph "Recommendations for the Management of Crush Victims in Mass Disasters", which may help provide effective health care to disaster victims with renal problems. This article discusses medical and logistic principles of the treatment of crush victims, both at the disaster field and on admission to hospitals, and guidance is described. The importance of early fluid administration even before extrication of the victims and avoidance of potassium-containing solutions during the treatment of crush victims is underlined. Also, the logistic problems in treating crush casualties are emphasized. The most important aspects of the recently published recommendations are highlighted.

Lessons from Haiti on Disaster Relief

Recent disasters have raised awareness within the nephrology community of the challenges faced by patients with ESRD and by those at risk for acute kidney injury (AKI) during these devastating situations (1–3). Given time constraints during disasters, limited resources, and the vulnerable populations who are often involved, the kidney community recognizes the value of an organized response. The term “renal disaster” was introduced by the International Society of Nephrology (ISN) Commission on Acute Renal Failure to underscore the many crush syndrome victims who required medical treatment or dialysis support after earthquakes in Armenia, China, and Turkey (4–8). ISN founded the Renal Disaster Relief Task Force (RDRTF) in 1989 to support patients with kidney injury or disease in disaster areas. Having a partnership with Medecins Sans Frontieres (also known as Doctors Without Borders), ISN RDRTF sends medical personnel, offers logistical advice on handling and distributing medical supplies, provides education on crush syndrome and AKI, and supplements local dialysis efforts (9–11). ISN provided clinical and dialysis support during the 1999 earthquake in Marmara, Turkey (11), the 2003 Bam earthquake in Iran, and the 2005 earthquake in Kashmir, Pakistan (7,12,13) and provided advice and assessment during the recent earthquakes in Southeast Asia and L'Aquila, Italy, last year (14,15). In the United States, a different type of disaster occurred after Hurricane Katrina struck the U.S. Gulf Coast in August 2005, causing widespread destruction. Katrina—the deadliest and costliest U.S. hurricane since 1928—forced more than 1 million people to evacuate the region. Although hurricanes typically provide enough advance warning for dialysis patients to leave the affected areas, many patients did not evacuate before Katrina hit the Gulf Coast. Many ESRD patients missed treatments and required hospitalization for medical and psychosocial problems (16 …

When the Earth Trembles in the Americas: The Experience of Haiti and Chile 2010

The response of the nephrological community to the Haiti and Chile earthquakes which occurred in the first months of 2010 is described. In Haiti, renal support was organized by the Renal Disaster Relief Task Force (RDRTF) of the International Society of Nephrology (ISN) in close collaboration with Médecins Sans Frontières (MSF), and covered both patients with acute kidney injury (AKI) and patients with chronic kidney disease (CKD). The majority of AKI patients (19/27) suffered from crush syndrome and recovered their kidney function. The remaining 8 patients with AKI showed acute-to-chronic renal failure with very low recovery rates. The intervention of the RDRTF-ISN involved 25 volunteers of 9 nationalities, lasted exactly 2 months, and was characterized by major organizational difficulties and problems to create awareness among other rescue teams regarding the availability of dialysis possibilities. Part of the Haitian patients with AKI reached the Dominican Republic (DR) and received their therapy there. The nephrological community in the DR was able to cope with this extra patient load. In both Haiti and the DR, dialysis treatment was able to be prevented in at least 40 patients by screening and adequate fluid administration. Since laboratory facilities were destroyed in Port-au-Prince and were thus lacking during the first weeks of the intervention, the use from the very beginning on of a point-of-care device (i-STAT®) was very efficient for the detection of aberrant kidney function and electrolyte parameters. In Chile, nephrological problems were essentially related to difficulties delivering dialysis treatment to CKD patients, due to the damage to several units. This necessitated the reallocation of patients and the adaptation of their schedules. The problems could be handled by the local nephrologists. These observations illustrate that local and international preparedness might be life-saving if renal problems occur in earthquake circumstances.

The D&T Report

The D&T Report

Haiti and elsewhere: global disaster nephrology

On 12 January 2010, a major earthquake struck Port-au-Prince, Haiti. Immediately, the International Society of Nephrology (ISN) Renal Disaster Relief Task Force—a worldwide network of experts in the management of patients with acute kidney injury (AKI)—swung into action. Within 12 hours an assessment team—a nephrologist and a nurse—flew out. The next day, a technician and another nurse flew out with equipment including four dialysis machines, a water treatment system, and a chemistry device for spot measurements of creatinine and potassium. Their hand luggage was full of crucial lightweight items including resonium and dialysis catheters.

The role of the Renal Disaster Relief Task Force

The role of the Renal Disaster Relief Task Force

Chronic Diseases and Natural Hazards: Impact of Disasters on Diabetic, Renal, and Cardiac Patients

Inadequately controlled chronic diseases may present a threat to life and well-being during the emergency response phase of disasters. Chronic disease exacerbations (CDE) account for one of the largest patient populations during disasters, and patients are at increased risk for adverse outcomes. The objective of this study was to assess the burden of chronic renal failure, diabetes, and cardiovascular disease during disasters due to natural hazards, identify impediments to care, and propose solutions to improve the disaster preparation and management of CDE. A thorough search of the PubMed, Ovid, and Medline databases was performed. Dr. Miller's personal international experiences treating CDE after disasters due to natural hazards, such as the 2005 Kashmir earthquake, are included. Chronic disease exacerbations comprise a sizable disease burden during disasters related to natural hazards. Surveys estimate that 25-40% of those living in the regions affected by hurricanes Katrina and Rita lived with at least one chronic disease. Chronic illness accounted for 33% of visits, peaking 10 days after hurricane landfall. The international nephrology community has responded to dialysis needs by forming a well-organized and effective organization called the Renal Disaster Relief Task Force (RDRTF). The response to the needs of diabetic and cardiac patients has been less vigorous. Patients must be familiar with emergency diet and renal fluid restriction plans, possible modification of dialysis schedules and methods, and rescue treatments such as the administration of kayexalate. Facilities may consider investing in water-independent extracorporeal dialysis techniques as a rescue treatment. In addition to patient databases and medical alert identification, diabetics should maintain an emergency medical kit. Diabetic patients must be taught and practice the carbohydrate counting technique. In addition to improved planning, responding agencies and organizations must bring adequate supplies and medications to care for diabetic, cardiac, and renal patients during relief efforts. By recognizing and addressing impediments to the care of chronic disease exacerbations after natural disasters, the quality, delivery, and effectiveness of the care provided to diabetic patients during relief efforts can be improved.

THE ROLE OF THE RENAL DISASTER RELIEF TASK FORCE IN THE PREVENTION AND TREATMENT OF CRUSH SYNDROME IN MASS DISASTERS

If natural or man-made disasters induce the collapse of solid structures such as buildings or rocks, victims might be trapped under the rubble. They frequently develop Crush Syndrome at extrication when their muscles are decompressed. A substantial number of victims suffering from Crush Syndrome will develop Acute Kidney Injury (AKI), and this often necessitates extensive medical intervention, fi rstly to prevent AKI and at a later stage to install treatment by means of dialysis. AKI is a life-threatening condition which one can, however, survive in case of appropriate therapy. To defi ne this type of disaster, the term Renal Disaster has been introduced (1). THE ROLE OF THE RENAL DISASTER RELIEF TASK FORCE IN THE PREVENTION AND TREATMENT OF CRUSH SYNDROME IN MASS DISASTERS

EARTHQUAKE IN PAKISTAN — THE RENAL DISASTER RELIEF TASK FORCE IN ACTION

Following an earthquake, an International stream of help is launched. Teams of nephrologists, renal nurses and technicians from many European countries are ready as volunteers to come into action when needed. Basic help is necessary but what is the benefit of nephrologists and renal nurses, as the Renal Disaster Relief Task Force comes into action? The scouting team assesses the situation in the disaster area. Treatment of acute renal failure, hyperkalemia and Crush Syndrome can be life saving. The ability to accommodate dialysis treatment is investigated, in collaboration with local nephrologists. Belgian, French, Irish and Turkish colleagues who made up two teams, with Médecins sans Frontières (MsF) left for Pakistan following the devastating earthquake in October 2005. This is a report from one of the volunteers from the first team explaining the individual contribution that his mission made to the disaster.

Intervention of the renal disaster relief task force (RDRTF) in the Kashmir earthquake

Intervention of the renal disaster relief task force (RDRTF) in the Kashmir earthquake

The organization and interventions of the ISN Renal Disaster Relief Task Force.

This article describes first the organization of the ISN Renal Disaster Relief Task Force-European branch founded by the ISN Commission on ARF. The task force aims at rapid dialysis intervention in case of acute disasters associated with a high number of ARF cases caused by crush syndrome. The organization involves European volunteers consisting of nephrologists, dialysis nurses, and technicians willing to go to disaster areas as far as India, the Middle East, and North Africa to assist the local nephrologic communities. In addition, an important role in the organization is played by Médecins sans Frontiières, the industry, and several nurses' and technicians' associations. The major intervention of the task force was at the occasion of the Marmara earthquake in Turkey in 1999. Additional more recent and minor interventions occurred in India and Algeria.