Renal Disaster Relief Arrives in Haiti
A patient receives medical treatment at a field hospital in Port-au-Prince, Haiti.
After a January 12 earthquake ravaged Haiti's cities and towns and killed more than 200,000 people, Bernard G. Jaar, MD, MPH, FASN, was on his way to help.
“As a nephrologist, I know too well the possible consequences of crush injuries with acute kidney injury,” Dr. Jaar said. “I believe that I was in a unique position to help in the Haiti earthquake.”
Dr. Jaar was born and raised in Port-au-Prince, the nation's capital, where he also attended the State University of Haiti medical school. Besides knowing Haiti well, he is fluent in the country's most widely spoken languages, French and Creole, as well as English, and he has a “good working knowledge of Spanish.” This linguistic ability was important because many relief personnel spoke only English or Spanish, a language barrier that made it difficult to provide emergency care.
Dr. Jaar did not go to Haiti, however. Instead, on January 22, he arrived at Jimani, a small town in the Dominican Republic about one kilometer from the Haitian border, carrying with him 10 acute hemodialysis catheters and 900 grams of sodium polystyrene (Kayexalate) to treat hyperkalemia, a potential complication of crush injuries.
“Hundreds of Haitian patients fled to the Dominican Republic in the first few days after the earthquake to seek medical care,” Dr. Jaar related. “Many Haitian patients were transferred to Jimani or brought by family members seeking medical care.”
As expected, the most common kidney problems were related to crush injuries with rhabdomyolysis—the release of myoglobin (which is toxic to the kidney) and potassium by damaged muscles—but several patients had more mild to moderate acute kidney injury (AKI) cases due to severe dehydration. The border region is dry, with temperatures in the high 90s and no easy access to drinking water, he explained.
In addition to a language barrier between Haitian patients and the many relief workers who came from around the world, medical personnel had to work with little or no laboratory support. “Initially, we had to rely essentially on history and physical exams to assess volume of urine and color of urine, but after 48 hours, we were able to measure serum BUN and creatinine,” said Dr. Jaar, Assistant Professor of Medicine and Epidemiology at Johns Hopkins University School of Medicine in Baltimore and Staff Nephrologist at the Nephrology Center of Maryland. He and other medical personnel identified two patients with severe AKI. One patient was transferred to the U.S. Navy's hospital ship, the USNS Comfort, and another was transferred to Barahona, another community in the Dominican Republic, for care by a local nephrologist.
For the first five days after he arrived, he and others had to rely on EKG changes to assess for and treat hyperkalemia. Then an iSTAT machine—a handheld, point-of-care blood analyzer—became available so caregivers could measure potassium.
Furthermore, doctors and other medical personnel had to treat patients in makeshift hospitals where patients had no real room or beds assigned, making it difficult to find patients to provide longitudinal care, Dr. Jaar noted.
Most patients diagnosed and treated for AKI in this situation have a good prognosis in terms of their renal health, but he anticipates that a minority of patients will remain dialysis dependent, he said. Dr. Jaar said he is in contact with a local nephrologist in Port-au-Prince to see how he could help with renal replacement therapy long-term in Haiti.
Haiti is widely regarded as the poorest nation in the Western Hemisphere, with little medical infrastructure. Bruce Molitoris, MD, who has been involved in the relief efforts coordinated by the American Society of Nephrology (ASN), noted that Haiti had only four known nephrologists for its nine million people.
He, too, pointed out that one of the major problems in Haiti early on was the inability to analyze blood because of the paucity of laboratory services. Few physicians in the disaster zone were thinking of rhabdomyolisis and AKI, which are silent conditions, “so you probably had people perish from hyperkalemia and acute renal failure,” Dr. Molitoris said. In time, Abbott, the pharmaceutical company, supplied iSTAT units, which it makes.
ASN helped to recruit 60 physicians who have offered to provide assistance on the ground or to accept patients in the United States. It also played a key role in coordinating efforts of the Kidney Community Emergency Response Coalition (KCER), large dialysis organizations, and other groups, said Dr. Molitoris, Chair of the Nephrology Division and Professor of Medicine at Indiana University Medical School in Indianapolis.
At the ASN annual meeting last November, he noted, all of the principal players who would be involved in renal disaster relief gathered for a symposium, which “really started the foundation for an interactive group.”
“Serendipitously, we were much better prepared [for the disaster in Haiti] than we would have been because of that symposium,” he said.
Still, in the first few days after the magnitude 7.0 earthquake struck, relief workers faced formidable obstacles to delivering aid, including impassable roads, a lack of electricity and water, and poor communication. Members of the International Society of Nephrology's Renal Disaster Relief Task Force (RDRTF) were among those trying to provide emergency aid. An RDRTF assessment team left for the Dominican Republic from Paris on January 14. Accompanying the team (consisting of a nephrologist and a nephrology nurse) were four dialysis machines and a water treatment system. After arriving in the Dominican Republic, the team traveled to Port-au-Prince with the equipment, where they were joined by other RDRTF team members. The team managed to establish a dialysis unit in the city.