Get an inside look at how Brenner & Rector's The Kidney approaches disaster nephrology — from crush syndrome and AKI to dialysis continuity, transplant recipients, displaced patients, and disaster preparedness strategies for kidney care providers.
For 50 years, the world’s most well-known kidney reference Order your copy today at elsevierhealth.com/9780443106415 From Brenner & Rector’s The Kidney, 2 volume set, 12th Edition Exclusive preview: Disaster Nephrology SECTION XIV — ChallENgES IN NEphrOlOgy 2364 affected both physically and emotionally, because of limited self- preservation skills and dependence on their parents or caregivers. 19 Additionally, as compared with adults, children are more at risk of polytrauma and skull injuries, malnutrition, and dehydration because of their anatomic and physiologic characteristics. 123,128,132- 135 Harm may occur even in the prenatal period. Major concerns in that phase are intrauterine growth retardation, prematurity, and maternal mental disorders, which may cause long-lasting health problems including kidney damage. 136,137 However, despite all these extra risks, special needs of pediatric patients are often neglected in general disaster preparedness scenarios. 138 risK reDuCtioN aND resPoNse Preparing communities and individuals appropriately for disasters in the predisaster period is vital to minimize postdisaster disorganization, panic, and chaos. This is extremely useful to prevent inappropriate reflexes and interventions during the intradisaster period and optimize outcomes of the victims. In the postdisaster period, evaluation of the adequacy of preparations and the response is important to avoid repeating mistakes in future calamities (Fig. 82.4). 31,34,139- 141 PreDisaster PerioD (Disaster PrePareDNess) All- hAzArDs APProAch Different types of disasters (e.g., earthquakes, wars, hurricanes, pandemics, flooding) may cause similar practical problems (e.g., disorganization, panic, chaos, disruption of essential infrastructural services, shortages of housing and nutrition, interruptions in communication and transportation, disparity between health care demand and supply, unsecure environments). 139,142- 144 However, demography and medical and logistic features of the victims may vary among different types of disasters (e.g., crushed patients in destructive disasters, gunshot or explosion- related injuries resulting from wars, drowned victims after flooding and tsunamis, widespread infection during pandemics). 8 Therefore preparations should be valid for all types of disasters (i.e., the “all-hazards approach,” which means managing different disasters according to a common plan) 142- 144 but also must be complemented by a more focused disaster/disease-specific approach. This combination allows tailoring of the disaster response to the circumstances of each disaster and identifies the most pragmatic strategy for an efficient response. 31,34,140,142- 144 Details regarding the “all-hazards approach” have been described elsewhere. 142- 144 In this chapter, we focus on “renal disaster preparedness” strategies on a regional basis to minimize disaster-related risks for people with acute and chronic kidney diseases. renAl DIsAsTer–focuseD PrePAreDness Preparing simple, clear, and pragmatic algorithms, which focus on particular disasters, is useful to avoid major medical and logistic errors due to panic, confusion, and inexperience during or in the early minutes after disasters (Figs. 82.5, 82.6, and 82.7). Overall, renal disaster preparedness encompasses several complex steps, summarized in Fig. 82.4. ComPosing Disaster resPonse teams Many stakeholders contribute to disaster response, and their commitment should already begin before disasters by generating intervention plans, continue during the acute phase of the disaster by implementing rescue and therapeutic interventions, and end after the disaster by rehabilitating the victims and evaluating the overall response. Assigning trained and experienced disaster relief coordinators (DRCs) is crucial to achieve several tasks (Table 82.2). 31,47,139,145 A critical task of DRCs is preparing scenarios by dividing the country into sectors, each with an assigned local (sector) coordinator, to collaborate in conducting national/regional disaster response and support. Sector coordinators assess the working capacity of local personnel in their region, arrange personnel and material help for the affected region, and coordinate relocation of disaster Table 82.1 Differences in Various Features of Pediatric versus Adult Patients with Kidney Diseases During Disasters 5,16,125-131 Feature Comments Overall health concerns • Malnutrition is more prominent in children • Children are more prone to communicable diseases in unhygienic environments • Breakdowns in vaccination programs are more frequent in children Medical concerns related with kidney care • Prerenal AKI may be more frequent in children • Incidence of crush syndrome-related AKI is lower in the first decade of life • Prevalence of pediatric patients on KRT is lower than adult patients • There is less skilled pediatric health care personnel • Children are less compliant to dietary restrictions • Children are more susceptible to complications due to missed dialysis sessions Logistic problems related to KRT patients • Obtaining pediatric-sized HD and PD equipment is more problematic • Unavailability of pediatric drug formulations is more frequent • Shortage of specialized pediatric dialysis personnel is more prominent General organizational problems • Pediatric kidney patients are usually not included in preparedness plans • Many children are separated from their caregivers and are unaccompanied AKI, Acute kidney injury; HD, hemodialysis; KRT, kidney replacement therapy; PD, peritoneal dialysis. Fig. 82.4 An overview of risk reduction, re- sponse, and retrospective evaluation of the response in various phases of disasters. The all-hazards approach combined with the renal disaster–specific model in the predisaster period should be followed by application of predefined action plans and management of anticipated or instant/unexpected logistic problems. Manage- ment of patients with various problems related to kidney diseases, which are often even more se- vere in displaced kidney patients and in children, is a critical part of the intervention at this stage. In the postdisaster period, overall predisaster preparations and intradisaster response are eval- uated, shortcomings in response are identified, and measures are defined to avoid repetition in future disasters. 31,34,139-141 PREDISASTER PERIOD (DISASTER PREPAREDNESS) INTRADISASTER PERIOD (INTERVENTIONS) POSTDISASTER PERIOD (EVALUATION OF THE PREPAREDNESS AND RESPONSE) All-hazards approach Composing response teams: - Coordinators, rescuers and other medical personnel Training: - Rescue team members - Kidney health care staff - Patients Planning of dialysis provision - Dialysis facilities - Supplies - Personnel Preparations for: - Command system - Control system - Communication - Safety and security preservation - Triage - Surge capacity - Human resources “Renal disaster” specific model • Application of the predefined action plans • Management of immediate logistic problems • Redistribution of dialysis personnel and patients • Asking help from outside • Referral of patients to other regions • Management of patients with various kidney diseases • Specific care for displaced kidney patients • Specific care for pediatric patients • Assessment of short-term and long-term sequelae for kidney patients • Evaluation of disaster response by debriefing sessions DISASTER RISK REDUCTION AND RESPONSE Check your own and relative’s health status. In case of any problems try to get medical help Leave present location, if dangerous. Move to a safe place Make ready and pack personal goods / instruments a , necessary documents b If impossible, intervene by own initiative, locally If impossible, try to reach usual work place, and act according to predisaster plans Try to contact attending physician or treatment center to get instructions, and act as suggested If impossible, try self-management Make ready and pack personal goods / medications c , necessary documents d KIDNEY HEALTH CARE PROVIDER PATIENT WITH KIDNEY DISEASE A A B B DISASTER Try to contact disaster relief coordinator to get instructions, and act as suggested Fig. 82.5 Example of a simple, clear, and informative algorithm to minimize chaos and panic immediately after experiencing a destructive disaster (e.g., earthquake, war, hurricane). This algorithm describes early actions from the perspectives of kidney care providers (A) and patients with kidney diseases (B). Similar algorithms and/or infographics may (should) be created on various topics targeting the health care personnel or rescuers (e.g., interventions at the disaster field, issues to be considered for patient transport, indications for various medical interventions) or for the patients (e.g., how to secure themselves during the acute episode of a disaster, dietary suggestions, and simple instructions for self-treatment). a Instruments: e.g., personal medical instruments kept at home. b Necessary documents: e.g., action plans, treatment algorithms, and contact lists. c Medications: e.g., immunosuppressants, antihypertensives, antidiabetics, and other critical medications. d Necessary documents: e.g., medical reports, prescriptions, and treatment details. 31,139 CHAPTER 82 — DisAsTER NEPHRology 2367 medications) is crucial for patients. These supplies must be rotated regularly to prevent expiry and waste in the long term. Such simple measures have not yet been widely applied, even in well-developed, disaster-prone countries, such as Japan 91 or the United States. 146,147 An acute disaster episode may occur when hemodialysis patients are connected to their dialysis machines. Due to panic and extreme workload, staff may not be able to disconnect patients immediately; therefore self-disconnection, either by “clamp and cut” 148 or “clamp and cap” 149 techniques, should be A victim is detected under the rubble Duration of extrication process >2 h Reduce isotonic saline (0.5 L/h for adults; 10 mL/kg/h for children or even less) No fluid is given BEFORE EXTRICATION DURING EXTRICATION No vein can be found Initiate isotonic saline (1 L/h for adults; 15-20 mL/kg/h for children) A vein is found A vein issought in one of the limbs Continue isotonic saline (1 L/h for adults; 15-20 mL/kg/h for children) (no fluids could be given before rescue) (was receiving isotonic saline during rescue) Continue isotonic saline (Monitor for 6 hours since initiation of fluids) Close monitoring impossible Close monitoring possible Initiate isotonic saline IV fluid during 6 hours** (>6 L/day for adults; 3-6 L/m 2 /day for children) IV fluid* (0.5-1L/day for adults; 400 mL/m 2 /day for children + all presumed losses of the previous day) Administer overall 3-6 L (for children, 1.5-2 L/m 2 ) of fluid (subject to adaptation depending on several variables) AFTER EXTRICATION Anuria Urine output (+) IV fluid** (3-6 L/day) Fig. 82.7 Fluid administration protocol to prevent crush-related AKI for entrapped victims of destructive disasters before, during, and after extrication. 155,156 The intravenous route is preferred; however, if this cannot be achieved, intraosseous infusion may be considered as well, although this intervention may be impossible in chaotic disaster field conditions. If neither intravenous nor intraosseous accesses are possible, hypodermoclysis (subcutaneous infusion of isotonic fluids) at a rate of approximately 1 mL/min may be considered as a last resort. Up to 3 L/day of fluids can be given by this route; therefore it is not the ideal route for patients needing large volumes of fluids. Patients with skin or bleeding disorders or peripheral edema may not be appropriate candidates for hypodermoclysis. 153 Although oral rehydration is a possibility in alert patients with no risk of intraabdominal pathology and no need for imminent anesthesia, 154 exclusion of these probabilities may be problematic, especially in destructive disasters. (Modified with permission from Sever MS, Vanholder R. Management of crush victims in mass disasters: highlights from recently published recommen- dations. Clin J Am Soc Nephrol. 2013;8(2):328–335.) *Please see the text for advantages and disadvantages of various types of fluids. **Intensive fluid protocol is continued until disappearance of myoglobinuria (normalization of the urinary color), which usually occurs within 2 to 3 days following trauma; this fluid regimen is reduced or stopped in case of volume overload. 34,157 SECTION XIV — ChallENgES IN NEphrOlOgy 2366 victims from the affected area for temporary rescue dialysis or maintenance treatment elsewhere in their region. 131,139 Rescuers directly intervene in the disaster field, and kidney health care providers treat victims in health care facilities. Therefore selection, training, and assignment of these people according to personal skills and experience are essential to save as many lives as possible (Table 82.3). 31,47,139,140,145 The most effective disaster response can be achieved by executing tasks that are specified by the DRCs; however, if these coordinators cannot be reached, rescue or medical personnel should take appropriate initiatives by themselves (see Fig. 82.5). 31,139 organizing training aCtivities Since all disasters are life-threatening, training of response team members to preserve their own security and that of their relatives should be the first step of preparation. Apart from that, training courses should target various tasks for different health care providers: • Rescue team members should be trained on field interventions, triage practices, treatment of urgent problems on the spot and during transportation, and various other tasks (see Table 82.3). Overall, training courses should be adapted to anticipated disasters (i.e., first aid in gunshot injuries in wars, extrication and preventive measures for crush syndrome in destructive disasters, and helping drowned victims during flooding). 31 • Training courses for kidney health care providers should define early actions immediately after the disaster (see Fig. 82.5A), considering the disaster in focus. For example, dialysis nurses should be trained to not only dialyze injured victims but also disconnect patients from the machines and take other necessary actions (e.g., evacuation from the dialysis units, first aid for the victims, or triage practices) should a disaster occur during an ongoing dialysis session. 31 • The first target in patient education should be to minimize panic reactions and describe the first response during the acute phase and early after destructive disasters (see Fig. 82.5B). Training sessions should also provide information on emergency patient preparedness plans, kidney-disease diet, and avoiding complications (e.g., how to avoid being injured during destructive disasters; contracting infections in pandemics and unhygienic disaster conditions), as well as self-management strategies if relevant medical personnel cannot be contacted (Table 82.4). 31,47,139,145,146 Composing and updating a personal stock of medications and supplies (e.g., PD solutions and immunosuppressive Informs third parties* and initiates the action plan The DRC is not functioning / unavailable 2 hrs. The first substitute replaces and takes over the functions of the DRC 2 hrs. 2 hrs. The first substitute DRC is not functioning / unavailable The third substitute DRC is not functioning / unavailable 2 hrs. DISASTER RELIEF COORDINATOR (DRC) The second substitute replaces and takes over the functions of the DRC The third substitute replaces and takes over the functions of the DRC A predefined distant coordinator replaces and takes over the functions of DRC The second substitute DRC is not functioning / unavailable THE ACTION PLAN • Brief third parties* and initiate the prespecified action plan • Define status of local health care provision • Define patient flow to health facilities; assess the need for external help • Make (personnel/material) help calls to national and international bodies • Forward help received to the locations in need • Inform policy makers about status of kidney patients to obtain their support • Offer educational material and algorithms to the personnel • Try to refer the patients to the other regions within the country or abroad • Inform scientific community on the outcomes of kidney patients 2 hrs. DISASTER Fig. 82.6 Renal disaster action plans for emergency response and organizing relief. Within the first 2 hours of the disaster, the disaster relief coordinator (DRC) should brief third parties and initiate the action plan. If the DRC cannot function or is not reachable within the first 2 hours, the first local substitute will be automatically assigned. If the first local substitute does not respond or cannot be reached, the second local substitute will act as the DRC. This scenario is repeated unless even the third local substitute cannot be reached. In the latter case, a predefined distant co- ordinator (the fourth substitute) will take over the functions of the DRC. This pragmatic strategy has been effective in past disasters, particularly in the case of communication problems. Adaptations to the action plan considering the type and extent of the disaster, the status of the predisaster and postdisaster general and health care infrastructure of the affected region and country, and local circumstances may be necessary. (Adapted with permission from Sever MS, Lameire N, Vanholder R. Renal disaster relief: from theory to practice. Nephrol Dial Transplant. 2009;24(6):1730–1735.) *Third parties: authorities, substitute DRCs, the president of the local nephrology society and the nephrology community. Unlock the power of AI in clinical decision making Access Brenner & Rector’s The Kidney, through ClinicalKey AI, a clinical decision support tool that combines trusted, evidence-based content with advanced generative AI. Learn more about ClinicalKey AI.
Order your copy of Brenner & Rector’s The Kidney, 2 volume set, 12th Edition at elsevierhealth.com/9780443106415 2359 Disaster Nephrology Mehmet Sukru Sever | Lale Sever | Raymond Vanholder Disasters Disasters, either natural or man-made, result in “serious disruptions of the functioning of a society associated with widespread individual, material, economic or environmental losses.” 1 Natural disasters (earthquakes, hurricanes, pandemics) arise from a sudden major upheaval of nature, whereas man-made disasters (wars, terrorist attacks, nuclear disasters) develop as a consequence of damaging actions of humans. Disasters may be “destructive” (characterized by total or partial destruction of physical assets (e.g., in case of wars, earthquakes, and hurricanes) or “nondestructive” (which may result in extensive harm, however, with no structural 82 Key Points • During massive disasters, the entire spectrum of patients with kidney diseases (i.e., those with acute kidney injury, chronic kidney disease not on kidney replacement therapy, and kidney failure on dialysis or with a functioning transplant) are at higher risk compared with the healthy population. • Pediatric patients with kidney diseases, especially those with kidney failure, constitute an even higher risk group, especially if they are unaccompanied by caregivers. • The only way to improve outcomes is to prepare for an effective response in the predisaster period at the regional, national, and international levels, which can minimize the extent of medical problems, as well as postdisaster chaos, confusion, and disorganization. • All stakeholders (rescue team members, health care providers, authorities, patients, and their caregivers) should be trained on how to cope with disaster-related medical and logistic problems. • Major steps in disaster response are implementation of predefined action plans, handling of immediate logistic problems, and management of patients with various kidney diseases. • If the needs of patients with kidney diseases cannot be coped with locally, request for personnel and material support from outside becomes mandatory. • When structural and infrastructural damage is extensive and provision of local health care becomes impossible, the only solution will be evacuation, which adds further risks for patients with kidney diseases. • Professional societies should consider preparing guidelines for management of patients with kidney diseases in disaster conditions and providing education on disaster medicine, which differs considerably from routine medical practice. CHAPteR oUtLine Disasters, 2359 Challenges in ProviDing KiDney Care During Disasters, 2360 sPeCifiC Problems in Patients with KiDney Diseases, 2361 risK reDuCtion anD resPonse, 2364 PreDisaster PerioD (Disaster PrePareDness), 2364 intraDisaster PerioD (Disaster resPonse), 2369 PostDisaster PerioD (evaluation of the resPonse), 2372 ethiCal issues in ProviDing KiDney health Care During Disasters, 2372
Order your copy of Brenner & Rector’s The Kidney, 2 volume set, 12th Edition at elsevierhealth.com/9780443106415 SECTION XIV — ChallENgES IN NEphrOlOgy 2360 Increased number of patients (uniformly increased in all disasters) • Acute myocardial infarction • Hypertensive emergencies • Gynecologic/obstetrical problems • Seizures Physical hazards for healthcare personnel • Personal injuries • Death • Suboptimal living conditions • Transportation difficulties Deficient functioning of healthcare personnel • Chaos, panic, confusion • Disorganization • Lack of experience • Burnout Ineffective healthcare provision Increased workload Increased number of patients (specific for some disasters) • Wars gunshot injuries • Earthquakes crush trauma • Flooding drowning • Pandemics infections Damage to general infrastructure • Power outages • Lack of tap water • Deficient transportation • Deficient communication Damage to healthcare infrastructure, e.g.: • Hospitals • Dialysis units • Warehouses Inefficient work Fig. 82.1 Reasons for ineffective health care provision during massive disasters. When damage to general and health care infrastructure combines with shortage of skilled health care workforce, deficient health care is inevitable. An increased number of patients further increases these drawbacks (list of included factors in each box is not exhaustive). (From Sever MS, Pawlowicz-Szlarska E, Tuglular ZS. Nephrology in disasters, epidemics and wartime. In: Ronco C, Bellomo R, House A, et al, eds. ERA Neph-Manual. European Renal Association; 2024. Accessed 3 March 2025. https://e-learning.era-online.org/ebook/chapter-22-nephrology-in-disasters-epidemics-and-wartime.) damage; e.g., during pandemics or droughts). Although a significant year-by-year variation exists, overall, there is a trend for an increase in the number of both natural 2 and man-made disasters over time, 3,4 at least in part related to political, cultural, and religious conflicts; growing world population; and an increase in mobility and environmental changes (e.g., global warming). MeDIcAl ProbleMs AfTer DIsAsTers Medical problems caused by disasters may be “disaster specific” (e.g., increased risk of crush syndrome after destructive events, 5,6 drowning after floods, 7 gunshot wounds during wars). 8-10 However, other medical threats increase uniformly with all types of disasters, such as the risk of developing acute myocardial infarction, stroke, seizures, or acute exacerbations of preexisting chronic diseases (e.g., hyperglycemia or ketoacidosis in diabetes, 11 uncontrolled hypertension, 11,12 and exacerbations in other chronic diseases) 13,14 due to disaster-related logistic drawbacks. Logistic difficulties contribute to the dimension of medical problems. When increased numbers of patients due to disaster-related or disaster- unrelated reasons are superimposed on damaged general and health care infrastructure, health care provision becomes ineffective. Substandard work of the health personnel will exaggerate these drawbacks (Fig. 82.1). 15-17 ChalleNges iN ProviDiNg KiDNey Care DuriNg Disasters Overall, medical concerns are more prominent in vulnerable patients (i.e., elderly, frail, women, children, and all people with noncommunicable diseases). This is also the case for individuals with acute or chronic kidney disease due to many factors, including 8,14,18-29 : • Increased number of acute and chronic patients per unit is a frequent epiphenomenon of destructive and nondestructive disasters. 5,30,31 For example, in the COVID-19 pandemic, acute kidney injury (AKI) incidence was 46% in all hospitalized victims; this figure increased to 76% in patients admitted to intensive care units (ICUs). 32 After the Marmara earthquake in 1999, 639 patients with AKI due to crush injuries were registered and 5137 sessions of hemodialysis were required in these patients. 33 Furthermore, due to movement of chronic patients from nonfunctioning dialysis units, there was also a relative increase in the workload in functional facilities. 34,35 • Damage to infrastructure is a major problem for patients with kidney diseases. Those who need dialysis are exposed to the highest risk, arising from disruptions in water and electricity, difficulties with communication and transportation, and damage to hospital buildings and/or dialysis units/machines/materials, which all interfere with dialysis services. 31,35-45 Also, extensive chaos, panic, and disorganization, even in high-income and disaster-prone countries, may result in adverse outcomes. 17,26,41,46 • Shortage of specific therapeutics is a major obstacle for patients with kidney diseases, who need many medications and supplies for treatment and survival. These items include but are not limited to peritoneal dialysis (PD) solutions, heparin, immunosuppressants, erythropoiesis-stimulating agents, antihypertensives, phosphate binders, and vitamin D and iron preparations. 39,47 • Shortage of well-trained personnel (e.g., hemodialysis technicians, kidney nurses, nephrologists, and medical professionals involved with other specialties) is frequent during disasters due to personal injuries, transportation problems, concerns related with family members or personal property, and everyday family responsibilities. 48,49 Concerningly, despite extensive literature, 31 awareness and knowledge about kidney problems during disasters remain disappointing among authorities, policymakers, rescuers,
Order your copy of Brenner & Rector’s The Kidney, 2 volume set, 12th Edition at elsevierhealth.com/9780443106415 CHAPTER 82 — DisAsTER NEPHRology 2361 the public, and most medical professionals. Therefore major shortcomings persist in health care provision because of not only disparity between health care demand and supply but also disaster-related specific problems in patients with various kidney diseases. Risk reduction and appropriate responses are extremely complex under these circumstances (Fig. 82.2). chAngIng concePTs: froM “renAl DIsAsTer” To “DIsAsTer nePhrology” The link between massive disasters and a high number of patients with kidney disease was first recognized in the aftermath of the Spitak-Armenia earthquake in 1988, when 600 victims suffered from crush-related AKI. 30 Almost all of these victims died due to lack of dialysis support; subsequently, the term “renal disaster” was introduced and the Renal Disaster Relief Task Force of the International Society of Nephrology was created. 50 After the Marmara earthquake in Turkey in 1999, the concept of “seismonephrology” or “earthquake-nephrology” was developed, highlighting the frequent occurrence of AKI in the victims rescued from collapsed buildings. 51 Afterwards, however, considering the effects of Hurricane Katrina on patients with kidney diseases 41 and potential threats by other disasters (e.g., wars, tsunamis, pandemics) that may disrupt care of maintenance dialysis patients and individuals living with a functioning kidney transplant, the more encompassing term “disaster nephrology” was suggested. 52,53 sPeCifiC Problems iN PatieNts with KiDNey Diseases PATIenTs WITh AKI An increase in the number of patients with AKI due to different pathogenetic mechanisms has been observed in various disasters. 54 earthquaKes Several etiologies (e.g., bleeding-related hypoperfusion of the kidneys, transfusion reactions, dehydration after having been trapped in confined spaces, high incidence of infections and sepsis, exposure to nephrotoxic medications during treatment of complications) may play a role in the pathogenesis of earthquake-related AKI. 31,54,55 However, crush syndrome is the most frequent cause 30,31 and has been reported in up to 5% of all earthquake victims. 5,56,57 The first step in the pathogenesis of crush-related AKI is development of traumatic rhabdomyolysis in patients trapped under the rubble (Fig. 82.3). 58-62 This is followed by development of systemic responses forming the basis of the crush syndrome. For example, hypotension may develop due to hypovolemia secondary to fluid third-spacing in the muscle compartments; hyperkalemia may develop due to traumatic rhabdomyolysis and acidosis-induced efflux of potassium from the muscle cells; disseminated intravascular coagulation may be triggered by increased serum levels of thromboplastin released from injured muscles; and infections may result from contamination in traumatic/ surgical wounds and unhygienic circumstances. 5,56,57,63-65 Many mechanisms may play a role in the development of crush-related AKI 54,59-61 : 1. intravascular volume depletion may result in renal hypoperfusion and ischemia; 2. muscular trauma increases serum myoglobin levels, which leads to myoglobinuria with subsequent intratubular cast formation and direct tubular toxicity of myoglobin; myoglobin scavenges nitric oxide and activates inflammatory pathways, all of which may contribute to kidney hypoperfusion and tissue injury; 3. high levels of serum uric acid originating from disintegrating cell nuclei may further contribute to cast formation and tubular obstruction; and 4. hyperkalemia and hypocalcemia-induced cardiac output depression may potentiate renal hypoperfusion. wars The true incidence of AKI during wars is uncertain due to challenges with detection, diagnosis, and registration, Fig. 82.2 Spectrum of health care concerns in “disaster nephrology.” During massive disasters, extra health care problems are added to routine demand, whereas health care provision is limited due to logistic reasons. Specific disaster-related problems in patients with kidney diseases exaggerate the dimensions of the crisis. Risk reduction by means of predisaster preparedness and response during the active phase of the disaster may only partially solve the problems. Retrospective evaluation of the response is mandatory to avoid similar mistakes in future disasters. Overall, drawbacks may be even more important in displaced patients and children. Of note, many ethical controversies exist in fair distribution of limited medical supplies and manpower. AKI, Acute kidney injury; CKD, chronic kidney disease; KRT, kidney replacement therapy. Health care concerns in “Disaster nephrology” Challenges in providing kidney care during disasters Lack of: • Preparedness • Response • Response evaluation • Displaced patients • Pediatric patients • Ethical issues • Increased demand • Limited supply, due to: • Damaged infrastructure • Problematic access to care • Shortage of specific drugs • Shortage of expert personnel • Transportation problems Failures in risk reduction and adequate response • Patients with AKI • Patients with CKD (not on KRT) • Dialysis patients • Transplant recipients • Displaced patients • Pediatric patients Specific problems in patients with kidney diseases
Order your copy of Brenner & Rector’s The Kidney, 2 volume set, 12th Edition at elsevierhealth.com/9780443106415 SECTION XIV — ChallENgES IN NEphrOlOgy 2362 although many factors may result in prerenal, intrinsic renal, and postrenal AKI. That is, prerenal AKI may develop due to gunshot injuries or penetrating trauma-induced bleeding and subsequent hypovolemia, and intrinsic AKI may occur on the basis of ischemic acute tubular necrosis due to prolonged prerenal states or myoglobinuric and hemoglobinuric acute tubular necrosis due to crush injuries and transfusion reactions, respectively. 6,10,34,55,66 Exposure to chemicals and airborne toxins leading to nephrotoxic acute tubular necrosis, sepsis-related AKI, and gunshot-related direct injury to the kidneys are other important causes of intrinsic AKI during conflicts. Postrenal AKI may result from urinary tract obstruction due to pelvic trauma and foreign bodies within the urinary tract. 10,34 These mechanisms apply similarly to terrorist attacks, which may involve gunshot injuries, explosions, and building collapses. 67 other Disasters Pandemics drew the attention of the medical community during and after the COVID-19 disaster, when several reports defined a high incidence of AKI. 32,38,68-73 A detailed discussion of COVID-19–related AKI is provided in Chapter 59. AKI may also follow other man-made disasters such as traffic accidents and torture , 74,75 meteorologic disasters, 7 or malaria 76 and leptospirosis 77 during floods. However, data on these events are scarce. Historically, outcomes of AKI after disasters remained dismal for many years, with mortality rates up to 41% in earthquake victims who needed dialysis support 78 and 53% in victims of wars. 79 Recently, these figures improved to nearly 20% among the recent earthquake-crush 80- 82 and war-AKI victims. 83 Over the long term, AKI may result in chronic kidney disease (CKD). This adverse outcome has been reported in both war victims 84 and patients who had suffered from COVID-19, 85 although this has not received enough attention up to now. PATIenTs WITh chronIc KIDney DIseAse noT on KIDney rePlAceMenT TherAPy If patients can survive the acute phase, and if preparedness is adequate, CKD may remain stable during short-lived disasters. However, exceptions do exist (e.g., increased risk of rapid CKD progression and a significant increase in Baromyopathy Intramuscular hemorrhage Compartment syndrome Direct traumatic impact-mediated myolysis Crush injury CRUSH INJURY–INDUCED TRAUMATIC RHABDOMYOLYSIS RHABDOMYOLYSIS–INDUCED CRUSH SYNDROME Traumatic rhabdomyolysis Activation of proteolytic enzymes Depletion of ATP Ischemic damage Decompression after rescue Restoration of perfusion Ischemia-reperfusion injury Other mechanisms Systemic manifestations* Hyperkalemia DIC Infections Hypotension AKI CRUSH SYNDROME 8 6 5 1 7 4 2 3 Fig. 82.3 Pathophysiology of traumatic rhabdomyolysis- induced crush syndrome. Overall, pathogenesis may be divided into two major phases: crush injury–induced traumatic rhabdomyolysis and rhabdomyolysis-induced crush syndrome. Mechanisms leading to development of rhabdomyolysis take place when the victims are still under the rubble (gray shaded) or after being extricated, but these phases may overlap as well. 1. The initial event is crush injury, which may trigger pathogenesis when the victim is still under the rubble and continues after the extrication. 2. The major pathogenetic mechanism under the rubble is baromyopathy (or pressure-stretch myopathy), which increases sarcolemmal permea- bility. 3. Shift of plasma water into the muscle tissue triggers development of the compartment syndrome, whereas influx of calcium into cytosol activates proteolytic enzymes causing further myocyte and microvascular damage. Depletion of adenosine triphosphate (ATP) stores, ischemic damage, and many other mechanisms may also contribute to the pathogenesis of traumatic rhabdomyolysis. 4. Intramuscular bleeding may fur- ther increase intracompartmental pressure. 5. However, most of the damage occurs after the victim has been rescued. 6. Flow into the damaged tissue results in ischemia-reperfusion injury, which is one of the most important pathogenetic mechanisms. 7. Disruption of myocytes by direct effects of trauma plays a minor role. 8. Traumatic rhabdomyolysis triggers several systemic manifestations, such as hypotension, hyperkalemia, acute kidney injury (AKI), disseminated intravascular coagulation (DIC), infections, and many others resulting in crush syndrome. (Please see the text for details of rhabdomyolysis-induced crush syndrome development). 58-62 *Systemic manifestations are not exhaustive.
Order your copy of Brenner & Rector’s The Kidney, 2 volume set, 12th Edition at elsevierhealth.com/9780443106415 CHAPTER 82 — DisAsTER NEPHRology 2363 dialysis initiation, especially in patients with hypertensive kidney disease, as experienced after the 2011 Great East Japan Earthquake and tsunami). 86 Standardized mortality rates for patients with CKD also increased in coastal areas after this earthquake. 87 Many factors (e.g., extreme stress, inability to obtain specific diet and medications, and shortage of experienced personnel) contribute to suboptimal treatment of underlying diseases 8,16,27,31,41,47,66 and consequent accelerated decline of kidney function. In protracted disasters, these risks are likely higher, although this has not been reported so far. The management of people with CKD receiving immunosuppressants may be affected in two different ways. On the one hand, the immunosuppressive therapy may increase the risk of infection if they are subjected to unhygienic conditions, on the other hand not being able to continue their treatment may increase the risk for relapse of worsening of their primary disease. 31 heMoDIAlysIs PATIenTs Across the whole spectrum of CKD, hemodialysis patients constitute the group at greatest risk during disasters, due to several reasons: 1. Shelling of dialysis centers, power outages, extreme weather, and infrastructural damage may cause disruptions of dialysis services. 39,40,88,89 2. Dialysis needs may increase in maintenance patients because lack of appropriate diet, shortage of medications, and/or impossibility to obtain appropriate treatment, all of which may trigger complications. 31,90,91 3. Increased incidence of AKI further amplifies dialysis shortage. 4. Patients may experience delays in arteriovenous fistula surgery due to increased need for other surgery or other reasons for increased pressure on the health care system. 16,92 5. Work overload, burnout, and panic may result in suboptimal health care provision or even malpractice by the dialysis personnel. 16,41,48 If an acute disaster (e.g., bombardment during wars or incident earthquakes) occurs when patients are connected to hemodialysis machines, patients themselves may attempt panicky disconnection, which increases the risks of extensive bleeding, subsequent hypotension, shock, and fistula problems. 31,66 All these factors may result in missed dialysis sessions, 35,38 underdialysis, and, consequently, increased frequency of interdialytic and intradialytic complications, 66,93,94 which are all associated with higher odds of hospitalization 95 and mortality. 16,89,96- 98 During disasters, high mortality rates have been reported among hemodialysis staff as well. 99 PerIToneAl DIAlysIs PATIenTs The main challenge is obtaining dialysis solutions and other supplies because of damage to warehouses and pharmacies, as well as problems with delivery. 100- 104 This drawback may contribute to inadequate dialysis and subsequent hypervolemia, electrolyte disturbances, heart failure, and hypertension. 103,105 Following destructive disasters, living in crowded shelters or camps 26 may increase the risks for peritonitis and exit-site and tunnel infections. 43 In patients on automated peritoneal dialysis (APD), two problems deserve special mention: first, lack of electricity may interfere with its application; 66 second, panicky disconnection from APD machines at the moment of a disaster may lead to catheter damage, catheter dislocation, or peritoneal contamination. 103 Despite all these drawbacks, outcomes during disasters among patients on PD are more favorable than for hemodialysis patients, 106,107 although, at least in the case of the COVID-19 pandemic, in some regions around the globe, high mortality rates were reported among patients on PD. 104 TrAnsPlAnT recIPIenTs Logistic challenges, inadequate nutrition, dehydration, shortage of immunosuppressive medications, failure to perform optimal follow-up, and unavailability of experienced medical personnel may all adversely affect outcomes of patients living with a functioning transplant. 31,41,91,108- 110 Incident transplantation activity is usually postponed during short- term disasters. 41 Declines in new transplantation numbers are more dramatic in protracted disasters, as is the case of long-lasting wars or pandemics. 109,111,112 Most of the experience on the outcome of previously transplanted patients during disasters was reported after the COVID-19 disaster, during which people living with a functioning kidney transplant more frequently needed admission in the ICU 113 and had a higher mortality 114 than nontransplanted patients. The main reasons for these complicated courses and unfavorable outcomes were related to their immunosuppressed condition. 115 During a pandemic, minimizing immunosuppressive medications may decrease the risk of contracting the infection and its rapid progression, although this strategy may increase the possibility of rejection. 116,117 DIsPlAceD PeoPle WITh KIDney DIseAses Following a disaster, people may flee to another region in the same country (internally displaced people) or to another country (refugees). Risks faced by displaced patients with kidney diseases, especially by those with kidney failure, are more prominent than for the displaced healthy population both when traveling and in their new environment, because of disease-related and logistic drawbacks (i.e., more unhygienic and unsecure conditions, need for dialysis, immunosuppressive state, and associated comorbidities). 66,118-122 Especially in the case of rushed displacement, life-threatening complications occur because of challenges in receiving appropriate medical care, reaching a dialysis unit, and inadequate communication of medical information. 66 PeDIATrIc PATIenTs In natural disasters, up to 43% of acutely injured victims are children. 123 Every year, 175 million children around the world are estimated to be affected by natural disasters, and globally 449 million children—1 child out of 6—live in a conflict zone. 124 During disasters, the same general concerns observed in adult patients with kidney diseases also apply to pediatric kidney patients; however, differences may be noted with regard to a number of specific features (Table 82.1). 5,16,125-131 Children are at high risk of being
Order your copy of Brenner & Rector’s The Kidney, 2 volume set, 12th Edition at elsevierhealth.com/9780443106415 SECTION XIV — ChallENgES IN NEphrOlOgy 2364 affected both physically and emotionally, because of limited self- preservation skills and dependence on their parents or caregivers. 19 Additionally, as compared with adults, children are more at risk of polytrauma and skull injuries, malnutrition, and dehydration because of their anatomic and physiologic characteristics. 123,128,132- 135 Harm may occur even in the prenatal period. Major concerns in that phase are intrauterine growth retardation, prematurity, and maternal mental disorders, which may cause long- lasting health problems including kidney damage. 136,137 However, despite all these extra risks, special needs of pediatric patients are often neglected in general disaster preparedness scenarios. 138 risK reDuCtioN aND resPoNse Preparing communities and individuals appropriately for disasters in the predisaster period is vital to minimize postdisaster disorganization, panic, and chaos. This is extremely useful to prevent inappropriate reflexes and interventions during the intradisaster period and optimize outcomes of the victims. In the postdisaster period, evaluation of the adequacy of preparations and the response is important to avoid repeating mistakes in future calamities (Fig. 82.4). 31,34,139-141 PreDisaster PerioD (Disaster PrePareDNess) All- hAzArDs APProAch Different types of disasters (e.g., earthquakes, wars, hurricanes, pandemics, flooding) may cause similar practical problems (e.g., disorganization, panic, chaos, disruption of essential infrastructural services, shortages of housing and nutrition, interruptions in communication and transportation, disparity between health care demand and supply, unsecure environments). 139,142-144 However, demography and medical and logistic features of the victims may vary among different types of disasters (e.g., crushed patients in destructive disasters, gunshot or explosion- related injuries resulting from wars, drowned victims after flooding and tsunamis, widespread infection during pandemics). 8 Therefore preparations should be valid for all types of disasters (i.e., the “all-hazards approach,” which means managing different disasters according to a common plan) 142-144 but also must be complemented by a more focused disaster/disease-specific approach. This combination allows tailoring of the disaster response to the circumstances of each disaster and identifies the most pragmatic strategy for an efficient response. 31,34,140,142-144 Details regarding the “all-hazards approach” have been described elsewhere. 142-144 In this chapter, we focus on “renal disaster preparedness” strategies on a regional basis to minimize disaster-related risks for people with acute and chronic kidney diseases. renAl DIsAsTer–focuseD PrePAreDness Preparing simple, clear, and pragmatic algorithms, which focus on particular disasters, is useful to avoid major medical and logistic errors due to panic, confusion, and inexperience during or in the early minutes after disasters (Figs. 82.5, 82.6, and 82.7). Overall, renal disaster preparedness encompasses several complex steps, summarized in Fig. 82.4. ComPosing Disaster resPonse teams Many stakeholders contribute to disaster response, and their commitment should already begin before disasters by generating intervention plans, continue during the acute phase of the disaster by implementing rescue and therapeutic interventions, and end after the disaster by rehabilitating the victims and evaluating the overall response. Assigning trained and experienced disaster relief coordinators (DRCs) is crucial to achieve several tasks (Table 82.2). 31,47,139,145 A critical task of DRCs is preparing scenarios by dividing the country into sectors, each with an assigned local (sector) coordinator, to collaborate in conducting national/regional disaster response and support. Sector coordinators assess the working capacity of local personnel in their region, arrange personnel and material help for the affected region, and coordinate relocation of disaster Table 82.1 Differences in Various Features of Pediatric versus Adult Patients with Kidney Diseases During Disasters 5,16,125-131 Feature Comments Overall health concerns • Malnutrition is more prominent in children • Children are more prone to communicable diseases in unhygienic environments • Breakdowns in vaccination programs are more frequent in children Medical concerns related with kidney care • Prerenal AKI may be more frequent in children • Incidence of crush syndrome-related AKI is lower in the first decade of life • Prevalence of pediatric patients on KRT is lower than adult patients • There is less skilled pediatric health care personnel • Children are less compliant to dietary restrictions • Children are more susceptible to complications due to missed dialysis sessions Logistic problems related to KRT patients • Obtaining pediatric-sized HD and PD equipment is more problematic • Unavailability of pediatric drug formulations is more frequent • Shortage of specialized pediatric dialysis personnel is more prominent General organizational problems • Pediatric kidney patients are usually not included in preparedness plans • Many children are separated from their caregivers and are unaccompanied AKI, Acute kidney injury; HD, hemodialysis; KRT, kidney replacement therapy; PD, peritoneal dialysis.
Order your copy of Brenner & Rector’s The Kidney, 2 volume set, 12th Edition at elsevierhealth.com/9780443106415 Fig. 82.4 An overview of risk reduction, re- sponse, and retrospective evaluation of the response in various phases of disasters. The all-hazards approach combined with the renal disaster–specific model in the predisaster period should be followed by application of predefined action plans and management of anticipated or instant/unexpected logistic problems. Manage- ment of patients with various problems related to kidney diseases, which are often even more se- vere in displaced kidney patients and in children, is a critical part of the intervention at this stage. In the postdisaster period, overall predisaster preparations and intradisaster response are eval- uated, shortcomings in response are identified, and measures are defined to avoid repetition in future disasters. 31,34,139-141 PREDISASTER PERIOD (DISASTER PREPAREDNESS) INTRADISASTER PERIOD (INTERVENTIONS) POSTDISASTER PERIOD (EVALUATION OF THE PREPAREDNESS AND RESPONSE) All-hazards approach Composing response teams: - Coordinators, rescuers and other medical personnel Training: - Rescue team members - Kidney health care staff - Patients Planning of dialysis provision - Dialysis facilities - Supplies - Personnel Preparations for: - Command system - Control system - Communication - Safety and security preservation - Triage - Surge capacity - Human resources “Renal disaster” specific model • Application of the predefined action plans • Management of immediate logistic problems • Redistribution of dialysis personnel and patients • Asking help from outside • Referral of patients to other regions • Management of patients with various kidney diseases • Specific care for displaced kidney patients • Specific care for pediatric patients • Assessment of short-term and long-term sequelae for kidney patients • Evaluation of disaster response by debriefing sessions DISASTER RISK REDUCTION AND RESPONSE Check your own and relative’s health status. In case of any problems try to get medical help Leave present location, if dangerous. Move to a safe place Make ready and pack personal goods / instruments a , necessary documents b If impossible, intervene by own initiative, locally If impossible, try to reach usual work place, and act according to predisaster plans Try to contact attending physician or treatment center to get instructions, and act as suggested If impossible, try self-management Make ready and pack personal goods / medications c , necessary documents d KIDNEY HEALTH CARE PROVIDER PATIENT WITH KIDNEY DISEASE A A B B DISASTER Try to contact disaster relief coordinator to get instructions, and act as suggested Fig. 82.5 Example of a simple, clear, and informative algorithm to minimize chaos and panic immediately after experiencing a destructive disaster (e.g., earthquake, war, hurricane). This algorithm describes early actions from the perspectives of kidney care providers (A) and patients with kidney diseases (B). Similar algorithms and/or infographics may (should) be created on various topics targeting the health care personnel or rescuers (e.g., interventions at the disaster field, issues to be considered for patient transport, indications for various medical interventions) or for the patients (e.g., how to secure themselves during the acute episode of a disaster, dietary suggestions, and simple instructions for self-treatment). a Instruments: e.g., personal medical instruments kept at home. b Necessary documents: e.g., action plans, treatment algorithms, and contact lists. c Medications: e.g., immunosuppressants, antihypertensives, antidiabetics, and other critical medications. d Necessary documents: e.g., medical reports, prescriptions, and treatment details. 31,139