• Photo by Ed Kashi. A woman enduring CKD receives dialysis at the Rajiv Gandhi Medical Institute of Sciences in Srikakulam, India, on January 30, 2016.

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    Aoun M, Koubar SH. Impact of forced human migration on management of end-stage kidney disease in host countries. Semin Nephrol 2020; 40:363374. doi: 10.1016/j.semnephrol.2020.06.004

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    Alasfar S, et al. Dealing with dramatic health care problems during times of natural disaster and armed conflict. Kidney Int 2023; 104:221224. doi: 10.1016/j.kint.2023.05.003

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    Al-Jubori Y, et al. The efficacy of gum arabic in managing diseases: A systematic review of evidence-based clinical trials. Biomolecules 2023; 13:138. doi: 10.3390/biom13010138

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Hemodialysis in Times of War

Sahar H. Koubar Sahar H. Koubar, MBBS, is an assistant professor of medicine in the Division of Kidney Diseases and Hypertension, University of Minnesota, Minneapolis.

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Photo by Ed Kashi. A woman enduring CKD receives dialysis at the Rajiv Gandhi Medical Institute of Sciences in Srikakulam, India, on January 30, 2016.

Citation: Kidney News 16, 4

Author's Note: This article is dedicated to all patients on hemodialysis who have been disconnected from their lifelines during agonizing periods of war.

The pairing of “human” and “war” is a distressing combination yet still a confirmed reality of the 21st century. Ironically, many major medical advances have historically occurred during times of war. For example, the rotating drum dialyzer was deployed during the Korean War in 1952. This breakthrough invention, developed by Dr. Willem Kolff, who is considered to be one of the founding fathers of artificial organs, reduced mortality from crush injuries from 90% to 53% (1).

The population undergoing hemodialysis requires a sophisticated infrastructure to survive. During times of war, health priorities shift toward the wounded and injured, leaving such a population particularly vulnerable and adversely affected. Furthermore, contemporary wars predominantly occur in transitional countries that are already burdened by poor infrastructure and limited resources. This creates a greater need for international rescue and non-governmental organizations to provide the much-needed assistance and support to those patients. (2).

Medical facilities also bear the brunt of armed conflicts. Medical personnel are killed, health care facilities become targets of attacks, and there is a massive exodus of health workers (3, 4). In non-government-besieged northwest Syria, it is estimated that 1 nephrologist serves a population of 1 million, and only 6 out of 20 dialysis units have a supervising nephrologist (5). This scarcity of health care personnel has given rise to the concept of the “super technician.” In this role, the dialysis technician takes on the responsibilities of a nephrologist, dialysis nurse, dietitian, water-treatment specialist, machine maintenance personnel, and social worker.

Medical care can also be criminalized in opposition areas, supplies besieged, and international laws violated (3, 4). Wars can also lead to the destruction of infrastructure, resulting in the disconnection of patients on hemodialysis from their life-sustaining treatments. It is not uncommon for these patients to go without dialysis for 1 week or, tragically, succumb to their disease due to lack of treatment. Furthermore, those experiencing acute kidney injury, due to rhabdomyolysis resulting from crush injuries, may also have dialysis needs that go unmet.

Even in cases in which dialysis is being performed, the scarcity of resources results in poor-quality dialysis and unfavorable outcomes. For example, in Syria, the mortality rate is 2.5 times higher for patients receiving hemodialysis within the besieged areas compared with the non-affected areas (6). In the Iraq-Kuwait war, the mortality rate of patients who underwent hemodialysis and remained in the country was almost four times higher than those who fled Kuwait (7). Among Syrian refugees in Jordan, approximately 45% of individuals with a hemoglobin level below 8 g/dL have no access to erythropoietin-stimulating agents, and 14% were positive for hepatitis C virus (8).

Unexpected opportunities

The scarcity of available resources has led to some unexpected innovations. In one example, a rudimentary continuous renal replacement therapy (CRRT) machine, made of an extracted pump from a conventional dialysis machine and powered with a car battery (in the absence of electricity), using homemade dialysate, saved the life of three patients (9). Another CRRT machine, using ultrafiltration with intravenous saline as replacement fluid, set up in a school basement, stabilized the lives of 12 patients on chronic hemodialysis. Some of the measures implemented for patients on hemodialysis during armed conflicts are summarized in Table 1. Unfortunately, scarcity of resources often persist for patients on hemodialysis who are forcefully displaced into other, safer countries, as most neighboring countries also suffer from a fragile and crippled health system (10).

Table 1

Measures used to mitigate lack of dialysis in armed conflict zones

Table 1

Perhaps the collateral beauty of physician exodus is their unwavering dedication and commitment to their fellow citizens. Expat physicians facilitated and advanced much of the work needed by volunteering their service and efforts to guide on-the-ground medical personnel. They developed educational curriculum in areas with protracted conflicts, advocated for these vulnerable populations at international societies, and helped secure donations from supply companies (11). Their steadfast work is only second to the heroic efforts by the local doctors on the ground.

Overcoming the chaos of war highlights the importance of preparedness, organization, collaboration, and solidarity. The nature of war can politicize humanitarian aid; however, humanitarian efforts should be unhindered, as any disruption in providing care equates to a disruption in life itself. There should be zero tolerance to violate the Geneva Conventions and International Humanitarian Law Rule 25 (12). Thus, I call on international societies to take a more significant and proactive role globally in such cases without any limitations. It is only through concerted and unwavering international collaboration that we can mitigate the distressful impact of conflicts on the vulnerable population undergoing hemodialysis and ensure the provision of essential health care services, regardless of geographical boundaries or political constraints.

Footnotes

The author reports no conflicts of interest.

References

  • 1.

    Smith LH Jr, et al. Post-traumatic renal insufficiency in military casualties. II. Management, use of an artificial kidney, prognosis. Am J Med 1955; 18:187198. doi: 10.1016/0002-9343(55)90234-5

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Berhe E, et al. The despair of patients with kidney diseases in third-world wars: The case of Ethiopia's crisis. Nephrol Dial Transplant 2023; 38:20922095. doi: 10.1093/ndt/gfad093

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Fouad FM, et al. Health workers and the weaponization of health care in Syria: A preliminary inquiry for The Lancet-American University of Beirut Commission on Syria. Lancet 2017; 390:25162526. doi: 10.1016/S0140-6736(17)30741-9

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Arawi T. War on healthcare services in Gaza. Indian J Med Ethics (published online January 17, 2024). doi: 10.20529/IJME.2024.004

  • 5.

    Koubar SH, et al. Nephrology workforce and education in conflict zones. Kidney Int Rep 2021; 7:129132. doi: 10.1016/j.ekir.2021.11.024

  • 6.

    Isreb M, et al. Effect of besiegement on non-communicable diseases: Haemodialysis. Lancet 2016; 388:2350. doi: 10.1016/S0140-6736(16)32129-8

  • 7.

    el-Reshaid K, et al. The impact of Iraqi occupation on end-stage renal disease patients in Kuwait, 1990-1991. Nephrol Dial Transplant 1993; 8:710. doi: 10.1093/oxfordjournals.ndt.a092276

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Isreb MA, et al. The effect of war on Syrian refugees with end-stage renal disease. Kidney Int Rep 2017; 2:960963. doi: 10.1016/j.ekir.2017.05.009

  • 9.

    Rifai AO, et al. Continuous venovenous hemofiltration using a stand-alone blood pump for acute kidney injury in field hospitals in Syria. Kidney Int 2015; 87:254261. doi: 10.1038/ki.2014.334

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Aoun M, Koubar SH. Impact of forced human migration on management of end-stage kidney disease in host countries. Semin Nephrol 2020; 40:363374. doi: 10.1016/j.semnephrol.2020.06.004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Alasfar S, et al. Dealing with dramatic health care problems during times of natural disaster and armed conflict. Kidney Int 2023; 104:221224. doi: 10.1016/j.kint.2023.05.003

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    International Committee of the Red Cross (ICRC). International Humanitarian Law Databases. Rule 25. Medical personnel. https://ihl-databases.icrc.org/en/customary-ihl/v1/rule25

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Al-Jubori Y, et al. The efficacy of gum arabic in managing diseases: A systematic review of evidence-based clinical trials. Biomolecules 2023; 13:138. doi: 10.3390/biom13010138

    • PubMed
    • Search Google Scholar
    • Export Citation
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