Natural Disaster and Kidney Disease: How Prepared Are We?

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If you care for patients with any degree of kidney failure on a regular basis, you understand firsthand how vulnerable these patients are. Each aspect of their care requires careful planning and organization by a large multidisciplinary team, a feat that is challenging enough under normal circumstances. Now imagine trying to care for these patients with no running water and no electricity; imagine the roads to hospitals and dialysis unit being blocked by flooded water, debris, or by remnants of collapsed buildings. While this may seem like a scene from a low budget horror film, this has been the unfortunate reality for thousands of patients with kidney disease over the past few decades.

The 1988 Armenian earthquake was a 6.8 on the Richter scale, claiming the lives of 150,000 people and posing a disaster in kidney care with hundreds of patients suffering from crush injuries leading to acute kidney injury. In the wake of the Armenian earthquake, the Renal Disaster Relief Task Force (RDRTF) was established to provide coordinated international response to kidney failure after a major disaster including assessment of any needs, mobilization of resources and providing relief efforts. Flash forward to the 7.2 magnitude earthquake in Kobe, Japan that lead to 45,000 injuries and approximately 7,000 deaths. Over 2500 patients were affected by the earthquake, which lead the Japanese to develop a national network that gathered information on damage to dialysis units and formulated an action plan within one day of the natural disaster affected patients. Throughout the years, several more earthquakes took the lives of thousands of people; with each event came a unique set of challenges for relief efforts.

In more recent years, hurricanes have become more commonplace, posing their own challenges for relief efforts.  Hurricane Katrina, which made landfall on August 23, 2005, was regarded as the worst urban disaster in modern history claiming the lives of close to 2000 people along the Gulf coast. Katrina brought to light many deficiencies in our preparedness for handling disaster situations with regards to our patients with ESKD. As a result of massive amounts of rainfall and destructive winds, 94 dialysis units were closed for at least 1 week across the Gulf coast. Communication failures, water contamination, no designated shelters for patients on dialysis and limited resources were some of the deficiencies with the nephrology response during Hurricane Katrina. As a result, the Kidney Community Emergency Response was born, whose goal is to coordinate disaster preparedness and response to meet the needs of patients with renal failure in disaster situations. The efficacy of the KCER was put to the test during Hurricane Sandy in August 2012. Prior to the storm making landfall, contingency plans were in place to ensure that all patients received dialysis prior to landfall and extra supplies and generators were in place at all dialysis units to ensure that lack of power and supplies would be a roadblock to providing care for patients.  The emergency response to Sandy was much improved with that of Katrina, with the majority of dialysis units reopening within 5 days of landfall.

The emergency response systems would be challenged once again during Hurricane Harvey in August 2017.  Harvey was a Category 4 hurricane that brought with it winds gusting at up to 130 mph and dropped an estimated 34 trillion gallons of water over the state of Texas. An interview of Dr. Stephen Fadem, clinical professor at Baylor College of Medicine and Medial Director of one of the largest DaVita units in Houston revealed several successes in the emergency response system. First, the center had communicated with a nearby shelter to coordinate dialysis for patients, with 500 patients receiving dialysis over a three-day period. In addition to providing dialysis, DaVita also provided pop-up pharmacies to ensure that patients could get their medications. According to Dr. Fadem, the emergency response was far from perfect. Transportation remained an issue due to flooding and road closures. Another issue was lack of medical records for outside patients, with staff spending hours on the telephone trying to obtain clinical information necessary for care. This brings up the concern that there are still no reliable databases where relevant clinical information for patients with ESKD can be stored. Some of these challenges were highlighted on this post from 2017 by Ritu Patel.

As we continue to refine our emergency response systems in kiney failure disasters, we as nephrologists play an important role in educating our patients and our communities. In an emergency setting, we should educate our patients on an emergency diet plan to minimize hyperkalemia and volume overload. We should also educate emergency responders on the importance of timely dialysis treatments and work together as a nephrology community to ensure that all of our patients have access to care in a disaster situation.

Miraie Wardi, MD @miraie_wardi
Nephrology Fellow
Washington University in St. Louis

**Special thanks to Dr. Pooja Koolwal for the inspiration for this post!

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