Photo by Ed Kashi. A sugar cane cutter takes a hydration break from work in the fields at Ingenio San Antonio, or the San Antonio Sugar Mill, in Chichigalpa, Nicaragua, on February 29, 2020.
Citation: Kidney News 16, 4
The past 3 decades have seen a significant global impact of natural disasters, affecting approximately 5 billion people. In 2021, 432 natural disasters impacted 101.8 million individuals (1). Current practices are often difficult to uphold when significant threats emerge and become challenging to follow during disasters. Despite these challenges, health care remains a fundamental human right. Looking through a chronic illness lens, and more specifically from a kidney transplant perspective, the stakes are even higher. Below are some of the key aspects of transplantation that are frequently affected.
Patient and graft survival
During natural disasters, the continuity of transplant centers is severely affected due to the destruction of public services and the transplant infrastructure, financial instability, potential repurposing of medical workers, and limited medical supplies. The first wave of the COVID-19 pandemic underscored the vulnerability of kidney transplant recipients, with high mortality rates attributed to factors such as immunosuppression, comorbidities, and possible suboptimal health care (2). Insights from the pandemic and other natural disasters advocate for the continuation of transplantation programs during mass disasters under favorable conditions (3, 4). For displaced individuals, financial and language barriers, referral systems, and limited health care pose significant challenges. This necessitates local and international assistance to mitigate risks such as higher acute kidney injury incidence, infection risk, malnutrition, and lack of proper care in cases of kidney function deterioration (5, 6).
Immunosuppression management, outpatient follow-up, and the role of telemedicine
Medications can be in short supply in times of disasters, and access to them may be hindered. Establishing communication lines through non-governmental organizations and local groups can assist patients in obtaining medications. In cases in which usual drugs are unavailable, switching between immunosuppressive medications or adjusting the dosage of available drugs may be a viable option (4, 5). In some instances, patients can remain without optimal immunosuppression and be treated instead with high doses of steroids for months (5).
One of the proposed solutions to circumventing these issues is immunosuppression stocking, which might be limited by local regulations (5, 6). Since donations from humanitarian organizations might be unreliable for a longer duration due to unpredictable conditions, the creation of local registries containing information about medical institutions and contacts of medical suppliers would prove beneficial. These registries would calculate required medical supplies, relocate them to safer zones, help formulate plans for patient relocation, ensure the presence of medical personnel and supplies, and provide suggestions to medication adjustments based on their availability (7).
Communication between patients and physicians may also prove difficult. Telemedicine is valuable for non-transplant physicians managing patients undergoing transplant, especially for any modifications in immunosuppressants (7). Studies reported equivocal clinical endpoints for patients receiving video-based transplant care in disasters (7). Significant challenges for telemedicine encompass issues such as low literacy, limited computer technology familiarity, and the inability to connect to the internet.
The pre-transplantation evaluation and new kidney transplants
The pre-transplantation evaluation during disasters necessitates adherence to existing principles. The transplant program should continue to operate if strategically possible. Following Hurricane Katrina, there was a 21% decrease in kidney transplantations in Louisiana. This decline can be attributed primarily to the widespread chaos and panic, the closure of two out of three major transplant centers in New Orleans, a shortage of medical supplies, inefficiency, and burnout among medical personnel. Additionally, the reduction in the number of deceased donors was influenced by limited availability of intensive care unit (ICU) beds and restrictions on organ transport (8).
The first wave of the COVID-19 pandemic significantly impacted deceased and live-donor kidney transplantation, with global centers temporarily halting procedures. Living donor kidney transplantation was suspended in 67% of North American centers and 91% of European centers. In France, there was a significant reduction of up to 90.6% in deceased donor transplantation during the same period (2, 9). Subsequent waves had a milder impact, suggesting improved handling of medical and logistical challenges. A phased approach—prioritizing urgent cases and ensuring safe living donation—has been suggested to resume transplantation activities (2–4). Simulator models suggest a potential advantage of kidney transplantation in certain scenarios, and urgent indications may override concerns, allowing transplantation even in disasters (9–11).
Ethical issues
Mass disasters raise ethical dilemmas. These include performing kidney transplantation despite high morbidity and mortality risks, using ICU beds for potential deceased donors, and applying the same allocation rules as before the disaster. Classic ethical principles like non-maleficence, beneficence, distributive justice, and respect for autonomy should guide transplantation practices during disasters. Health care workers may face a higher risk of malpractice stemming from insufficient resources and by making medical decisions in unique scenarios not addressed by guidelines.
Clinical research
The absence of experimental models underscores the critical role of disaster-related clinical research. Despite methodological drawbacks, the pandemic emphasized the importance of cost-effective and high-quality research for future guidance, setting a path for the role of ongoing research. Continuing, ongoing clinical trials during disasters are desirable, with necessary protocol modifications to prevent study patients from facing additional risks (12).
Resuming care after disaster
Effective disaster response requires thorough preparation and ongoing evaluation of post-disaster interventions and rehabilitation. A phased approach is suggested for resuming transplantation activity, prioritizing urgent cases, and ensuring safe living donations (13–15).
In conclusion, managing kidney transplantation during disasters demands a multifaceted approach addressing logistical, ethical, and clinical challenges (Table 1 and Figure 1). Strategic planning, international collaboration, and ongoing research are key elements to ensure the survival and well-being of transplant recipients in the face of unforeseen crises.
Approaches to managing kidney transplantation during natural disasters
Coordination of natural disaster response
Citation: Kidney News 16, 4
Footnotes
References
- 1.↑
The International Disaster Database (EM-DAT). Inventorying hazards & disasters worldwide since 1988. Centre for Research on the Epidemiology of Disasters. Accessed January 28, 2024. https://www.emdat.be/
- 2.↑
Sever MS, et al. Kidney transplantation during mass disasters—from COVID-19 to other catastrophes: A consensus statement by the DESCARTES Working Group and Ethics Committee of the ERA. Nephrol Dial Transplant 2023; 38:300–308. doi: 10.1093/ndt/gfac251
- 3.↑
Hilbrands LB, et al.; ERACODA Collaborators. COVID-19-related mortality in kidney transplant and dialysis patients: Results of the ERACODA collaboration. Nephrol Dial Transplant 2020; 35:1973–1983. doi: 10.1093/ndt/gfaa261
- 4.↑
Kadowaki M, et al. Medication compliance in renal transplant patients during the Great East Japan Earthquake. Transplant Proc 2014; 46:610–612. doi: 10.1016/j.transproceed.2013.11.039
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Saeed B. The effect of the Syrian crisis on organ transplantation in Syria. Exp Clin Transplant 2015; 13:206–208. doi: 10.6002/ect.2014.0287
- 6.↑
Pawłowicz-Szlarska E, et al.; Renal Disaster Relief Task Force of the ERA. Distribution, preparedness and management of Ukrainian adult refugees on dialysis—an international survey by the Renal Disaster Relief Task Force of the European Renal Association. Nephrol Dial Transplant 2023; 38:2407–2415. doi: 10.1093/ndt/gfad073
- 7.↑
Vo AH, et al. University of Texas Medical Branch telemedicine disaster response and recovery: Lessons learned from hurricane Ike. Telemed J E Health 2010; 16:627–633. doi: 10.1089/tmj.2009.0162
- 8.↑
Kopp JB, et al. Kidney patient care in disasters: Lessons from the hurricanes and earthquake of 2005. Clin J Am Soc Nephrol 2007; 2:814–824. doi: 10.2215/CJN.03481006
- 9.↑
Loupy A, et al. Organ procurement and transplantation during the COVID-19 pandemic. Lancet 2020; 395:e95–e96. doi: 10.1016/S0140-6736(20)31040-0
- 10.
Roth AE, et al. Criminal, legal, and ethical kidney donation and transplantation: A conceptual framework to enable innovation. Transpl Int 2022; 35:10551. doi: 10.3389/ti.2022.10551
- 11.↑
Vanholder R, et al. Continuing kidney care in conflicts. Nat Rev Nephrol 2022; 18:479–480. doi: 10.1038/s41581-022-00588-7
- 12.↑
Kumar D, et al. COVID-19: A global transplant perspective on successfully navigating a pandemic. Am J Transplant 2020; 20:1773–1779. doi: 10.1111/ajt.15876
- 13.↑
Sharief S, et al. Disaster preparation in kidney transplant recipients: A questionnaire-based cohort study from a large United States transplant center. J Clin Nephrol 2018; 89:241–248. doi: 10.5414/CN109280
- 14.
PR Newswire. Ten years after Hurricane Katrina, Fresenius Medical Care remembers heroic stories, shares lessons learned. August 27, 2015. Accessed January 28, 2024. https://www.prnewswire.com/news-releases/ten-years-after-hurricane-katrina-fresenius-medical-care-remembers-heroic-stories-shares-lessons-learned-300134368.html
- 15.↑
Lameire N, et al. Role of the international and national renal organizations in natural disasters: Strategies for renal rescue. Semin Nephrol 2020; 40:393–407. doi: 10.1016/j.semnephrol.2020.06.007
