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Continuing kidney care in conflicts

Subjects

The devastating effects of war are far-reaching and particularly affect people with kidney disease. The Ukrainian conflict has highlighted problems encountered in the provision of support for this vulnerable group. On the basis of these and previous experiences in massive disasters, we propose a sustainable action plan to prepare for similar logistical challenges in future conflicts.

Numerous armed conflicts have occurred since the end of World War II. Some — including those in the Democratic Republic of Congo and the Tigray region of Ethiopia — continue to rage. In Europe, the invasion of Ukraine is the most ravaging conflict since 1945. Despite calls from the United Nations for a global ceasefire, conflicts remain a reality. Since its beginnings in February 2022, the Ukrainian conflict escalated quickly, with increasing numbers of attacks on civilians and critical infrastructure, including healthcare facilities. In such situations, many individuals will require medical attention, but capacity is often limited. Literature on best practices for continuing medical care during war is scarce1, especially for non-communicable diseases. Some insights can be drawn from experiences in natural disasters2. However, while natural disasters are devastating in their initial stages, they are generally followed by a stabilization period, which facilitates rescue and rebuilding. By contrast, conditions during periods of armed conflict generally remain unpredictable for prolonged periods.

Impact on patient care

Conflicts especially endanger patients with chronic illness because they can disrupt healthcare infrastructure, destroy facilities and limit travel required for care, accessing medical supplies, and the deployment of medical professionals. Healthcare professionals themselves may become victims or displaced, or suffer from burn-out3. People with kidney disease are especially vulnerable given the complexity and technicality of kidney care (Supplementary Table 1). Transplant recipients and other patients with chronic kidney disease, particularly those with diabetes and hypertension, require an uninterrupted supply of medications. Haemodialysis requires water and electricity; all forms of dialysis, but particularly peritoneal dialysis4, require robust supply and transport channels for consumables. Patients on in-centre haemodialysis must be able to commute for treatment.

People with kidney disease are especially vulnerable given the complexity and technicality of kidney care

Acute kidney injury places additional demands on healthcare systems and may further limit the availability of maintenance dialysis.

Even after moving to safer areas, chronically ill individuals remain vulnerable. Delays in accessing care in the context of unfamiliar surroundings can result in complications and increase the risk of disease progression. Thus, prospects of remaining in place and fleeing both impose a risk of treatment interruption, and either choice can be fatal.

The Ukrainian conflict

In the weeks preceding the invasion of Ukraine, precious time that could have been used for preparation was lost because a peaceful solution was expected. Once the conflict erupted, coordinating support proved challenging owing to the scale of the invasion, destruction and displacement of individuals. However, bordering and remote countries offered support, and several non-governmental organizations (NGOs) and the WHO have remained active in Ukraine.

In the first few weeks of the invasion, fewer people than expected requiring maintenance dialysis presented at the border. Numbers subsequently increased, but current estimates suggest that most of the ~10,000 patients who were receiving dialysis before the invasion remain in Ukraine. Many of these individuals have been displaced to Kyiv and western parts of Ukraine; an unknown number have missed dialysis sessions or died. Ukrainian doctors and nurses continue to provide care when possible, often with reduced numbers of weekly haemodialysis sessions. The widespread use of telemedicine has enabled continuity of therapeutic advice; however, telecommunication systems are vulnerable and can be hit, overloaded or disrupted by cyberattacks5. Dialysis supplies have been maintained so far through efforts of dialysis companies, the Ukrainian Ministry of Health (MOH) and the WHO. However, severe shortages of medications, such as tacrolimus, at one point threatened organ viability for approximately 1,500 kidney transplant recipients.

Outside Ukraine, those willing to help are struggling to channel support to maximal effectiveness. Transport of medical supplies into Ukraine has been disrupted by bombings, roadblocks and a reluctance of delivery personnel to transport materials. Some deliveries have been made through the actions of individuals and organizations; however, limited communication and coordination between these groups may have resulted in duplications of efforts. To aid efficiency, the European Renal Association (ERA) created a platform to centralize information relating to the demand and availability of supplies and services, including functioning dialysis centres in Ukraine and bordering countries, as well as attestations of patients’ need for dialysis6.

The Ukrainian nephrology community and MOH have communicated about the needs of patients with external organizations, such as the WHO and ERA, but a clear understanding of where patients are and what they require is difficult to obtain in such a fluid situation. The WHO, Médecins sans Frontières (Doctors without Borders), MOH, ERA, the European Society of Paediatric Nephrology and dialysis companies are actively collaborating to support the dialysis and medication needs of adults and children living with kidney disease. In the early stages of the conflict, the WHO provided 50 non-communicable disease emergency kits, with each kit enabling treatment of the most common conditions for 3 months for at least 10,000 patients7. Since then, the MOH has tried to maintain most healthcare services, including haemodialysis, and sends priority lists of essential medicines and supplies to external contacts, including the WHO.

Solutions

In response to the growing precariousness of the situation in Ukraine and bordering countries hosting refugees, the ERA convened a panel of experts in a task force to streamline nephrology support to Ukraine and Ukrainian refugees. This task force is reminiscent of the International Society of Nephrology’s Renal Disaster Relief Task Force (RDRTF–ISN), which was founded in 1989 to provide material and psychological support in the context of natural disasters8. RDRTF–ISN volunteers have so far not been deployed to conflict zones for reasons of safety and insurance. Nevertheless, the lessons learned by RDRTF–ISN have been valuable and enable practical recommendations to be made for the continued provision of kidney care in the acute phase of armed conflict (Supplementary Tables 2 and 3). We must now proactively think about future preparedness.

A primary need is to raise awareness of the link between disasters or conflicts and kidney problems among authorities and NGOs, who frequently consider cancer, diabetes, hypertension and communicable diseases, but do not necessarily appreciate the complexities of kidney care. Preparedness is essential for an appropriate response8,9. Nephrology preparedness plans should be developed for every country and facility, especially in high-risk areas but also elsewhere. This activity and subsequent actions should be organized by an independent coordinating institution without conflicts of interest — preferably one or more large nephrology societies — and supported by a task force of experts, including physicians, patients, industry, nurses and technicians, with a professional back office of sufficient capacity and resources. The task force should cover a well-defined geographic area. In response to specific events, the coordinating organization would provide a virtual ‘notice board’ whereby needs and offers of support could be communicated for centralized coordination of efforts. The initiative should involve well-trained young nephrology professionals available for deployment. Material procurement and shipments to those in need should be coordinated in collaboration with industry as well as the WHO and NGOs. In disaster-free periods, the task force should communicate regularly with its network regarding potential conflicts, threats and approaches. The WHO, NGOs, governments and professional organizations can play complementary roles to strengthen mutual emergency preparedness and response efforts10.

In a crisis situation, the efficacy of interventions should be optimized through regular updates on the locations of functioning dialysis units and kidney care centres in each region, with details of relevant contact persons. A local coordinator, along with back-ups, should be identified for each country or region. Concise recommendations, algorithms and infographics (Supplementary Fig. 1) should be developed to aid the management of patients and distributed in advance, and again with any event. Planning also requires that the therapeutic reserve capacity be defined for each country, with the implementation of strategies for patient education and empowerment and the development of evacuation plans specifying centres to which patients and professionals could relocate if their own unit becomes non-operational.

Finally, disaster nephrology should be included in medical and para-medical curricula and be an essential topic at nephrology congresses. Regular training courses for task force coordinators and members should be organized. The geopolitical situation forces a renewed sense of urgency for action by kidney care stakeholders. This momentum should not be lost and must be used to develop sustainable plans for the future.

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Acknowledgements

Further information can be found at https://www.era-online.org/en/help-for-ukraine/ and https://www.espn-online.org/ukraine-task-force.

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Correspondence to Raymond Vanholder.

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Vanholder, R., De Weggheleire, A., Ivanov, D.D. et al. Continuing kidney care in conflicts. Nat Rev Nephrol 18, 479–480 (2022). https://doi.org/10.1038/s41581-022-00588-7

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