Medical problems caused by disasters may be “disaster specific” (e.g., increased risk of crush syndrome after destructive events, ^, drowning after floods, gunshot wounds during wars). However, other medical threats increase uniformly with all types of disasters, such as the risk of developing acute myocardial infarction, stroke, seizures, or acute exacerbations of preexisting chronic diseases (e.g., hyperglycemia or ketoacidosis in diabetes, uncontrolled hypertension, ^, and exacerbations in other chronic diseases) ^, due to disaster-related logistic drawbacks. Logistic difficulties contribute to the dimension of medical problems. When increased numbers of patients due to disaster-related or disaster-unrelated reasons are superimposed on damaged general and health care infrastructure, health care provision becomes ineffective. Substandard work of the health personnel will exaggerate these drawbacks ( Fig. 82.1 ).

Reasons for ineffective health care provision during massive disasters.

When damage to general and health care infrastructure combines with shortage of skilled health care workforce, deficient health care is inevitable. An increased number of patients further increases these drawbacks (list of included factors in each box is not exhaustive).

From Sever MS, Pawlowicz-Szlarska E, Tuglular ZS. Nephrology in disasters, epidemics and wartime. In: Ronco C, Bellomo R, House A, et al, eds. ERA Neph-Manual. European Renal Association; 2024. Accessed 3 March 2025. https://e-learning.era-online.org/ebook/chapter-22-nephrology-in-disasters-epidemics-and-wartime .

The link between massive disasters and a high number of patients with kidney disease was first recognized in the aftermath of the Spitak-Armenia earthquake in 1988, when 600 victims suffered from crush-related AKI. Almost all of these victims died due to lack of dialysis support; subsequently, the term “renal disaster” was introduced and the Renal Disaster Relief Task Force of the International Society of Nephrology was created. After the Marmara earthquake in Turkey in 1999, the concept of “seismonephrology” or “earthquake-nephrology” was developed, highlighting the frequent occurrence of AKI in the victims rescued from collapsed buildings. Afterwards, however, considering the effects of Hurricane Katrina on patients with kidney diseases and potential threats by other disasters (e.g., wars, tsunamis, pandemics) that may disrupt care of maintenance dialysis patients and individuals living with a functioning kidney transplant, the more encompassing term “disaster nephrology” was suggested. ^,

An increase in the number of patients with AKI due to different pathogenetic mechanisms has been observed in various disasters.

Earthquakes

Several etiologies (e.g., bleeding-related hypoperfusion of the kidneys, transfusion reactions, dehydration after having been trapped in confined spaces, high incidence of infections and sepsis, exposure to nephrotoxic medications during treatment of complications) may play a role in the pathogenesis of earthquake-related AKI. ^{, ,} However, crush syndrome is the most frequent cause ^, and has been reported in up to 5% of all earthquake victims. ^{, ,} The first step in the pathogenesis of crush-related AKI is development of traumatic rhabdomyolysis in patients trapped under the rubble ( Fig. 82.3 ). This is followed by development of systemic responses forming the basis of the crush syndrome. For example, hypotension may develop due to hypovolemia secondary to fluid third-spacing in the muscle compartments; hyperkalemia may develop due to traumatic rhabdomyolysis and acidosis-induced efflux of potassium from the muscle cells; disseminated intravascular coagulation may be triggered by increased serum levels of thromboplastin released from injured muscles; and infections may result from contamination in traumatic/surgical wounds and unhygienic circumstances. ^{, , ,} Many mechanisms may play a role in the development of crush-related AKI ^, : 1. intravascular volume depletion may result in renal hypoperfusion and ischemia; 2. muscular trauma increases serum myoglobin levels, which leads to myoglobinuria with subsequent intratubular cast formation and direct tubular toxicity of myoglobin; myoglobin scavenges nitric oxide and activates inflammatory pathways, all of which may contribute to kidney hypoperfusion and tissue injury; 3. high levels of serum uric acid originating from disintegrating cell nuclei may further contribute to cast formation and tubular obstruction; and 4. hyperkalemia and hypocalcemia-induced cardiac output depression may potentiate renal hypoperfusion.

Pathophysiology of traumatic rhabdomyolysis-induced crush syndrome.

Overall, pathogenesis may be divided into two major phases: crush injury–induced traumatic rhabdomyolysis and rhabdomyolysis-induced crush syndrome. Mechanisms leading to development of rhabdomyolysis take place when the victims are still under the rubble (gray shaded) or after being extricated, but these phases may overlap as well. 1. The initial event is crush injury, which may trigger pathogenesis when the victim is still under the rubble and continues after the extrication. 2. The major pathogenetic mechanism under the rubble is baromyopathy (or pressure-stretch myopathy), which increases sarcolemmal permeability. 3. Shift of plasma water into the muscle tissue triggers development of the compartment syndrome, whereas influx of calcium into cytosol activates proteolytic enzymes causing further myocyte and microvascular damage. Depletion of adenosine triphosphate (ATP) stores, ischemic damage, and many other mechanisms may also contribute to the pathogenesis of traumatic rhabdomyolysis. 4. Intramuscular bleeding may further increase intracompartmental pressure. 5. However, most of the damage occurs after the victim has been rescued. 6. Flow into the damaged tissue results in ischemia-reperfusion injury, which is one of the most important pathogenetic mechanisms. 7. Disruption of myocytes by direct effects of trauma plays a minor role. 8. Traumatic rhabdomyolysis triggers several systemic manifestations, such as hypotension, hyperkalemia, acute kidney injury (AKI), disseminated intravascular coagulation (DIC), infections, and many others resulting in crush syndrome. (Please see the text for details of rhabdomyolysis-induced crush syndrome development). ∗Systemic manifestations are not exhaustive.

If patients can survive the acute phase, and if preparedness is adequate, CKD may remain stable during short-lived disasters. However, exceptions do exist (e.g., increased risk of rapid CKD progression and a significant increase in dialysis initiation, especially in patients with hypertensive kidney disease, as experienced after the 2011 Great East Japan Earthquake and tsunami). Standardized mortality rates for patients with CKD also increased in coastal areas after this earthquake. Many factors (e.g., extreme stress, inability to obtain specific diet and medications, and shortage of experienced personnel) contribute to suboptimal treatment of underlying diseases ^{, , , , , ,} and consequent accelerated decline of kidney function. In protracted disasters, these risks are likely higher, although this has not been reported so far.

The management of people with CKD receiving immunosuppressants may be affected in two different ways. On the one hand, the immunosuppressive therapy may increase the risk of infection if they are subjected to unhygienic conditions, on the other hand not being able to continue their treatment may increase the risk for relapse of worsening of their primary disease.

Across the whole spectrum of CKD, hemodialysis patients constitute the group at greatest risk during disasters, due to several reasons: 1. Shelling of dialysis centers, power outages, extreme weather, and infrastructural damage may cause disruptions of dialysis services. ^{, , ,} 2. Dialysis needs may increase in maintenance patients because lack of appropriate diet, shortage of medications, and/or impossibility to obtain appropriate treatment, all of which may trigger complications. ^{, ,} 3. Increased incidence of AKI further amplifies dialysis shortage. 4. Patients may experience delays in arteriovenous fistula surgery due to increased need for other surgery or other reasons for increased pressure on the health care system. ^, 5. Work overload, burnout, and panic may result in suboptimal health care provision or even malpractice by the dialysis personnel. ^{, ,}

If an acute disaster (e.g., bombardment during wars or incident earthquakes) occurs when patients are connected to hemodialysis machines, patients themselves may attempt panicky disconnection, which increases the risks of extensive bleeding, subsequent hypotension, shock, and fistula problems. ^,

All these factors may result in missed dialysis sessions, ^, underdialysis, and, consequently, increased frequency of interdialytic and intradialytic complications, ^{, ,} which are all associated with higher odds of hospitalization and mortality. ^{, ,} During disasters, high mortality rates have been reported among hemodialysis staff as well.

The main challenge is obtaining dialysis solutions and other supplies because of damage to warehouses and pharmacies, as well as problems with delivery. This drawback may contribute to inadequate dialysis and subsequent hypervolemia, electrolyte disturbances, heart failure, and hypertension. ^, Following destructive disasters, living in crowded shelters or camps may increase the risks for peritonitis and exit-site and tunnel infections. In patients on automated peritoneal dialysis (APD), two problems deserve special mention: first, lack of electricity may interfere with its application; second, panicky disconnection from APD machines at the moment of a disaster may lead to catheter damage, catheter dislocation, or peritoneal contamination.

Despite all these drawbacks, outcomes during disasters among patients on PD are more favorable than for hemodialysis patients, ^, although, at least in the case of the COVID-19 pandemic, in some regions around the globe, high mortality rates were reported among patients on PD.

Logistic challenges, inadequate nutrition, dehydration, shortage of immunosuppressive medications, failure to perform optimal follow-up, and unavailability of experienced medical personnel may all adversely affect outcomes of patients living with a functioning transplant. ^{, , ,}

Incident transplantation activity is usually postponed during short-term disasters. Declines in new transplantation numbers are more dramatic in protracted disasters, as is the case of long-lasting wars or pandemics. ^{, ,}

Most of the experience on the outcome of previously transplanted patients during disasters was reported after the COVID-19 disaster, during which people living with a functioning kidney transplant more frequently needed admission in the ICU and had a higher mortality than nontransplanted patients. The main reasons for these complicated courses and unfavorable outcomes were related to their immunosuppressed condition. During a pandemic, minimizing immunosuppressive medications may decrease the risk of contracting the infection and its rapid progression, although this strategy may increase the possibility of rejection. ^,

Following a disaster, people may flee to another region in the same country (internally displaced people) or to another country (refugees). Risks faced by displaced patients with kidney diseases, especially by those with kidney failure, are more prominent than for the displaced healthy population both when traveling and in their new environment, because of disease-related and logistic drawbacks (i.e., more unhygienic and unsecure conditions, need for dialysis, immunosuppressive state, and associated comorbidities). ^, Especially in the case of rushed displacement, life-threatening complications occur because of challenges in receiving appropriate medical care, reaching a dialysis unit, and inadequate communication of medical information.

In natural disasters, up to 43% of acutely injured victims are children. Every year, 175 million children around the world are estimated to be affected by natural disasters, and globally 449 million children—1 child out of 6—live in a conflict zone. During disasters, the same general concerns observed in adult patients with kidney diseases also apply to pediatric kidney patients; however, differences may be noted with regard to a number of specific features ( Table 82.1 ). ^{, ,} Children are at high risk of being affected both physically and emotionally, because of limited self-preservation skills and dependence on their parents or caregivers. Additionally, as compared with adults, children are more at risk of polytrauma and skull injuries, malnutrition, and dehydration because of their anatomic and physiologic characteristics. ^{, ,}

Harm may occur even in the prenatal period. Major concerns in that phase are intrauterine growth retardation, prematurity, and maternal mental disorders, which may cause long-lasting health problems including kidney damage. ^, However, despite all these extra risks, special needs of pediatric patients are often neglected in general disaster preparedness scenarios.

Different types of disasters (e.g., earthquakes, wars, hurricanes, pandemics, flooding) may cause similar practical problems (e.g., disorganization, panic, chaos, disruption of essential infrastructural services, shortages of housing and nutrition, interruptions in communication and transportation, disparity between health care demand and supply, unsecure environments). ^, However, demography and medical and logistic features of the victims may vary among different types of disasters (e.g., crushed patients in destructive disasters, gunshot or explosion-related injuries resulting from wars, drowned victims after flooding and tsunamis, widespread infection during pandemics). Therefore preparations should be valid for all types of disasters (i.e., the “all-hazards approach,” which means managing different disasters according to a common plan) but also must be complemented by a more focused disaster/disease-specific approach. This combination allows tailoring of the disaster response to the circumstances of each disaster and identifies the most pragmatic strategy for an efficient response. ^{, , ,} Details regarding the “all-hazards approach” have been described elsewhere. In this chapter, we focus on “renal disaster preparedness” strategies on a regional basis to minimize disaster-related risks for people with acute and chronic kidney diseases.

Preparing simple, clear, and pragmatic algorithms, which focus on particular disasters, is useful to avoid major medical and logistic errors due to panic, confusion, and inexperience during or in the early minutes after disasters ( Figs. 82.5, 82.6, and 82.7 ). Overall, renal disaster preparedness encompasses several complex steps, summarized in Fig. 82.4 .

Example of a simple, clear, and informative algorithm to minimize chaos and panic immediately after experiencing a destructive disaster (e.g., earthquake, war, hurricane).

This algorithm describes early actions from the perspectives of kidney care providers (A) and patients with kidney diseases (B). Similar algorithms and/or infographics may (should) be created on various topics targeting the health care personnel or rescuers (e.g., interventions at the disaster field, issues to be considered for patient transport, indications for various medical interventions) or for the patients (e.g., how to secure themselves during the acute episode of a disaster, dietary suggestions, and simple instructions for self-treatment).

^a Instruments: e.g., personal medical instruments kept at home.

^b Necessary documents: e.g., action plans, treatment algorithms, and contact lists.

^c Medications: e.g., immunosuppressants, antihypertensives, antidiabetics, and other critical medications.

^d Necessary documents: e.g., medical reports, prescriptions, and treatment details. ^,

Renal disaster action plans for emergency response and organizing relief.

Within the first 2 hours of the disaster, the disaster relief coordinator (DRC) should brief third parties and initiate the action plan. If the DRC cannot function or is not reachable within the first 2 hours, the first local substitute will be automatically assigned. If the first local substitute does not respond or cannot be reached, the second local substitute will act as the DRC. This scenario is repeated unless even the third local substitute cannot be reached. In the latter case, a predefined distant coordinator (the fourth substitute) will take over the functions of the DRC. This pragmatic strategy has been effective in past disasters, particularly in the case of communication problems. Adaptations to the action plan considering the type and extent of the disaster, the status of the predisaster and postdisaster general and health care infrastructure of the affected region and country, and local circumstances may be necessary.

Adapted with permission from Sever MS, Lameire N, Vanholder R. Renal disaster relief: from theory to practice. Nephrol Dial Transplant. 2009;24(6):1730–1735.

Fluid administration protocol to prevent crush-related AKI for entrapped victims of destructive disasters before, during, and after extrication. ^,

The intravenous route is preferred; however, if this cannot be achieved, intraosseous infusion may be considered as well, although this intervention may be impossible in chaotic disaster field conditions. If neither intravenous nor intraosseous accesses are possible, hypodermoclysis (subcutaneous infusion of isotonic fluids) at a rate of approximately 1 mL/min may be considered as a last resort. Up to 3 L/day of fluids can be given by this route; therefore it is not the ideal route for patients needing large volumes of fluids. Patients with skin or bleeding disorders or peripheral edema may not be appropriate candidates for hypodermoclysis. Although oral rehydration is a possibility in alert patients with no risk of intraabdominal pathology and no need for imminent anesthesia, exclusion of these probabilities may be problematic, especially in destructive disasters.

Modified with permission from Sever MS, Vanholder R. Management of crush victims in mass disasters: highlights from recently published recommendations. Clin J Am Soc Nephrol. 2013;8(2):328–335.

Renal disaster response is initiated by the DRC, who applies predefined action plans. If during destructive disasters the DRC becomes disabled for any reason, he or she is replaced by a prespecified substitute to take over his or her position for applying the action plans (see Table 82.2 ; Fig. 82.6 ). Even if overall principles apply to any disaster, there may be a need for adaptations according to the type and dimensions of the disaster.

These interventions are mostly focused on dialysis provision and may include but are not limited to. 1. Reassigning personnel from nonfunctioning to functioning units, which may reduce personnel shortages. Alternatively, working hours of personnel may need to be increased, however, with an increased risk of burnout and malpractice. 2. In case of a nonfunctioning dialysis unit, support from other units should be planned (e.g., by relocating the patients to surrounding functional units). 3. Referral of the maintenance in-hospital hemodialysis patients to nearby satellite units is useful to make space available in the hospital dialysis units for complex and acute patients, who may require tertiary hospitals and/or ICU admission. 4. Requests for material and/or dialysis personnel support from outside the disaster area or country have been useful. ^{, ,} However, these campaigns must be organized by coordinators with logistics experience and based on correct information from the affected area; otherwise, external help may be harmful. ^, Also, cost, politics, and logistics may be important barriers.

Evacuation of patients to other regions or even abroad may be considered if extensive damage makes local dialysis impossible. ^{, , ,} However, this option is complicated by the challenges of long-distance patient relocation.

Management strategies may differ according to the type and severity of the kidney disease, as well as the nature of the disaster. Therefore “to do list” priorities for the physicians (ideally nephrologists) may change ( Table 82.6 ).