This is an abridged version of the World Kidney Day 2023 scientific editorial published in Kidney International.
The United Nations Office for Disaster Risk Reduction defines a disaster as “a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts.” The global incidence of natural disasters is increasing, with the rate of disasters growing by at least 10-fold in one report from 1960 to 2020, with attendant increases in mortality, injuries, diseases, and disabilities. In 2021, natural disasters affected 101.8 million people worldwide, accounted for over 10,000 deaths, and caused approximately USD$252 billion in economic losses. In the same vein, at the end of 2021, 89.3 million people worldwide were forcibly displaced from their homes because of conflicts, violence, or fear of persecution and human rights violations, totaling more than twice the 42.7 million individuals displaced a decade ago and the most since the World War II.
Disruptions to dialysis care
Continue Reading
Individuals on dialysis are a particularly vulnerable group with respect to disasters. The critical consequences of a lack of access, coupled with an exponential increase in demand for dialysis as a result of trauma and injury from unexpected events, can lead to a critical failure of kidney services in an affected area. In 2005, the aftermath of Hurricane Katrina resulted in the closure of 94 dialysis facilities in the Gulf Coast of the United States, disrupting the continuity of life-sustaining treatment for existing patients on dialysis. Earthquakes in the Marmara region of Turkey in 1999 and Kashmir in 2005 led to a large spike in the number of patients with acute kidney injury due to crush injuries needing kidney replacement therapy. During the Marmara earthquake, 477 patients with acute kidney injury had emergency dialysis, most of whom would have died if dialysis treatment had not been available.
The COVID-19 pandemic has further highlighted that caring for patients with kidney disease is particularly challenging, especially with regard to dialysis patients who require complex and specialized team-based treatments in a system already overburdened with patients with COVID-19. Many hospitals dedicated most of their inpatient capacity to patients with acute COVID, admitting only those patients with other illnesses who were critically ill, with subacute inpatient care deferred to outpatient and home-based care.
In 2020, an online survey was conducted in Egypt to study the effects of the COVID-19 pandemic on the dialysis population at the Cairo University Children’s Hospital. With nearly 40% of patients traveling from outside greater Cairo and relying on multiple modes of public transport, almost half of the patients reported missing or arriving late for dialysis sessions. The study further reported that the financial consequences of quarantine requirements led to nutritional decline and had a significant psychological impact on patients and their caregivers. In India, the challenges due to the COVID-19 pandemic were enormous. With 3 months of lockdown where no public or private transportation was available, dialysis patients relied on the help of family and friends to travel for treatment. Staff often lived in medical units to provide treatment, and there was an overwhelming shortage of personal protective equipment. As in Egypt, the financial effects of severe lockdowns led to a lack of proper nutrition and medicines.
The vulnerability of dialysis patients can also be seen in man-made disasters such as war. Since the beginning of the Russian invasion of Ukraine, Ukrainian dialysis patients have suffered tremendously under the uncertainty of dialysis provisions coupled with the life-threatening horrors of the war. In Ukraine, there are currently over 10,000 dialysis patients, and more than 1500 individuals are living with a transplanted kidney. More than 800 medical facilities have been damaged since the beginning of the war, many of which are dialysis centers. Initial reports of extremely critical access to dialysis consumables were soon followed with reports of patient and staff cut off from dialysis centers because of missile attacks, bombardments, and active fighting on the ground. Many displaced patients and staff lived directly in dialysis centers. Although it has been recorded that some of these patients died, the outcome for most is unknown.
Disruptions to transplantation
Transplant services are often suspended in times of crisis, which leads to stress on the health care system. This was certainly the case for many countries in the early stages of the COVID-19 pandemic, with suspensions of waiting list activation in the setting of recent infections, some still ongoing. Also, access to essential immunosuppressive medications for kidney transplant recipients is often disrupted in the wake of a disaster, increasing the risk of rejection and allograft loss. This was appreciably experienced in Puerto Rico during Hurricane Maria in 2017, where the limitations in power, transportation, and communications posed significant challenges in ensuring that immunosuppressive drugs were delivered to patients.
A recent publication from the DESCARTES working group and ethics committee of the European Renal Association details the perils faced by kidney transplant recipients and kidney transplant programs in times of disaster. The authors strongly advocate for continued transplant services in addition to detailing the various logistic problems that are faced in times of disaster. However, they also note that postponing transplantations from living donors may be justified to reduce the risk of nosocomial infection and recommend early facility discharge for donors and recipients whenever possible. A number of concrete proposals are suggested, including patient education, adaptation to immunosuppressive therapy, and ensuring availability of local operational services. Importantly, the DESCARTES working group concludes that it is difficult to assess if and when it is appropriate to shut down kidney transplant programs during period of disaster but argues that “denying a life-saving therapy” is rarely justified.
Disaster response—optimizing care
As discussed, the dialysis population has been one of the most visibly affected groups during the COVID-19 pandemic, representative of a more general lack of disaster preparedness on a global scale. Many dialysis units were severely impacted at the beginning of the COVID-19 pandemic with problems managing schedules and keeping patients safe.
With time, a move toward telehealth improved communications, with increased attention to health literacy and multilevel information on how to handle acute COVID, distancing and immunization schedules. Many units implemented the rationalization approach, involving goal-oriented workflows to meet the needs of acute kidney injury, distancing requirements, and supply issues. In some areas, COVID-positive patients were cohorted for treatment in individual units. Many health systems thoroughly evaluated transplant recipients for risk of infection and used telemedicine for post-transplantation follow-up. From most reports, it is clear that transport issues were the most difficult to address.
Although home dialysis might be seen as preferrable treatment to address the problem of transport to dialysis units, in some situations, it is the uncertainty of power and water supply that affects all. Of note, after the Chi-Chi earthquake in Taiwan, automated peritoneal dialysis patients were switched to continuous ambulatory peritoneal dialysis as electricity supply became a problem. An international survey of the preparedness and management of the COVID-19 pandemic by dialysis units around the globe found disparate and patchy responses, though most had disaster plans in place before.
Conclusion and recommendations
Regardless of the scale of the event, optimal renal care demands a level of preparation for unexpected events. As disruption in kidney care is becoming more prevalent and likely to increase in the years to come, robust plans, personalized for patients, that are constantly reviewed and tested should be an essential part of a well-functioning kidney service.
For the community as a whole, a comprehensive, adaptive [public health emergency preparedness] framework with integrated kidney disease (NCD) emergency response may help reduce the difficulties experienced during disasters and aid in the capacity to recover services. Health systems need to be adaptive, robust, and resilient, incorporating the essential [public health emergency preparedness] elements to function optimally in and out of emergency/disasters. In the wake of the COVID-19 pandemic, we must continue to advocate for kidney disease to be included and integrated into preparedness plans, pre-emptively highlighting the importance of providing business-as-usual ongoing care for kidney patients during unexpected times.
Excerpted from
World Kidney Day Joint Steering Committee. Kidney health for all: preparedness for the unexpected in supporting the vulnerable. Kidney Int 103(3):436-443.
