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Disasters and kidney care: pitfalls and solutions

Nature Reviews Nephrology volume 19, pages 672–686 (2023)Cite this article

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Abstract

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

Key points

  • The numbers of man-made and natural disasters are increasing, with the greatest adverse effects in vulnerable populations, including older people, women, children and patients with non-communicable diseases (NCDs).

  • Among patients with NCDs, those with kidney failure require special attention because their survival during disasters depends upon functional infrastructure, advanced technology, the availability of specific drugs and well-trained medical personnel.

  • Although displacement during disasters may be preferred by some patients, additional problems that occur when travelling and/or in the new environment may have a negative impact on their prognosis.

  • Disaster-associated risks for patients with kidney disease may be mitigated by pre-disaster preparedness and training of various stakeholders, including the patients themselves.

  • Patients with acute kidney injury, chronic kidney disease or kidney failure should be evaluated after a disaster to identify any problems that were not detected during the disaster.

  • Retrospective analysis of the disaster response is necessary to identify and learn from mistakes and to avoid these during future events.

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Fig. 1: Main elements of the disaster response in ‘disaster nephrology’.
Fig. 2: Management of disaster-related problems for patients with kidney disease and their health-care providers.
Fig. 3: Renal disaster action plans for emergency response and organizing relief.
Fig. 4: Fluid resuscitation for patients with crush injuries before, during and after extrication from rubble.

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Acknowledgements

R.V. is President of the European Kidney Health Alliance (EKHA), which is a not-for-profit organization defending the case of patients with kidney disease and the nephrology community at the level of the European Commission. The EKHA network has five full members (the European Renal Association, the International Society of Nephrology, the European Kidney Patients Federation, the European Dialysis and Transplant Nurses Association/European Renal Care Association and the Dutch Kidney Foundation) as well as 30 national or regional societies that are affiliated members. The EKHA is the recipient of support from the European Union in the context of the Annual Work Programme 2022 on prevention of non-communicable diseases of EU4Health, topic ID EU4H-2022-PJ02, project no. 101101220 PREVENTCKD.

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Authors and Affiliations

  1. Istanbul University, Istanbul School of Medicine, Department of Nephrology, Istanbul, Turkey

    Mehmet Sukru Sever

  2. Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland

    Valerie Luyckx

  3. Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa

    Valerie Luyckx

  4. Renal Division, Brigham and Women’s Hospital, Harvard, Medical School, Boston, MA, USA

    Valerie Luyckx

  5. Department of Medicine, University of Calgary, Calgary, Alberta, Canada

    Marcello Tonelli

  6. Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

    Marcello Tonelli

  7. Division of Nephrology, Bezmialem Vakif University School of Medicine, Istanbul, Turkey

    Rumeyza Kazancioglu

  8. Independent Nurse Consultant, American Society of Nephrology, Washington, DC, USA

    Darlene Rodgers

  9. European Kidney Health Alliance, Brussels, Belgium

    Dani Gallego & Raymond Vanholder

  10. European Kidney Patient Federation, Wien, Austria

    Dani Gallego

  11. Marmara University, School of Medicine, Department of Nephrology, Istanbul, Turkey

    Serhan Tuglular

  12. Nephrology Section, Department of Internal Medicine and Paediatrics, University Hospital Ghent, Ghent, Belgium

    Raymond Vanholder

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Contributions

M.S.S., V.L., M.T., D.R. and R.V. researched data for the article. M.S.S., V.L., M.T., R.K., D.G., S.T. and R.V. contributed substantially to discussion of the content. M.S.S., D.R. and R.V. wrote the article. M.S.S., V.L., M.T., R.K., D.R., S.T. and R.V. reviewed and/or edited the manuscript before submission.

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Correspondence to Mehmet Sukru Sever.

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Glossary

Chronic kidney disease

Abnormalities of kidney structure or function that are present for longer than 3 months, with implications for health.

Crush syndrome

Crush injury and muscle damage-induced systemic manifestations, which may include, but are not limited to, hypovolaemic shock, acute kidney injury, electrolyte disturbances, sepsis, acute respiratory distress syndrome and disseminated intravascular coagulation.

Destructive disasters

Sudden calamitous events that result in huge amounts of damage, loss or destruction.

Kidney failure

Glomerular filtration rate <15 ml/min/1.73 m2. Kidney failure is characterized by signs and symptoms of uraemia or a requirement to initiate kidney replacement therapy (dialysis or transplantation).

Primary survey

A basic survey to identify and simultaneously treat life-threatening conditions. For pragmatic reasons, the injuries are surveyed in an orderly fashion based on the simple mnemonic, ABCDE (airway, breathing, circulation, disability, exposure).

Somatic symptoms

Subjective distress related to physical symptoms, which may include pain, gastroenterological, cardiovascular, genitourinary, neurological and other symptoms.

Third spacing

Fluid shifts into the interstitial spaces or into a body cavity that normally contain little fluid, such as the muscle compartments.

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Sever, M.S., Luyckx, V., Tonelli, M. et al. Disasters and kidney care: pitfalls and solutions. Nat Rev Nephrol 19, 672–686 (2023). https://doi.org/10.1038/s41581-023-00743-8

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