The Effect of War on Syrian Refugees With End-Stage Renal Disease

Chronic kidney disease and the global public health agenda: an international consensus

Early detection is a key strategy to prevent kidney disease, its progression and related complications, but numerous studies show that awareness of kidney disease at the population level is low. Therefore, increasing knowledge and implementing sustainable solutions for early detection of kidney disease are public health priorities. Economic and epidemiological data underscore why kidney disease should be placed on the global public health agenda - kidney disease prevalence is increasing globally and it is now the seventh leading risk factor for mortality worldwide. Moreover, demographic trends, the obesity epidemic and the sequelae of climate change are all likely to increase kidney disease prevalence further, with serious implications for survival, quality of life and health care spending worldwide. Importantly, the burden of kidney disease is highest among historically disadvantaged populations that often have limited access to optimal kidney disease therapies, which greatly contributes to current socioeconomic disparities in health outcomes. This joint statement from the International Society of Nephrology, European Renal Association and American Society of Nephrology, supported by three other regional nephrology societies, advocates for the inclusion of kidney disease in the current WHO statement on major non-communicable disease drivers of premature mortality.

Providing Hemodialysis in Unstable Areas: An Assessment and Framework for Effective Care

Introduction

Providing hemodialysis to patients with kidney failure (KF) in conflict-affected areas poses a significant challenge. Achieving and sustaining reasonable quality hemodialysis operations in such regions necessitates a comprehensive approach.

Methods

In the conflict area of Northwest (NW) Syria, a 3-phase project was initiated to address the quality of hemodialysis operations. The assessment phase involved the examination of infection prevention and control (IPC) protocols, staff training, medical protocols, individualized hemodialysis prescriptions, and laboratory testing capabilities. The second phase involved activities toward capacity building and implementing an action plan based on feasibility and sustainability.

Results

The assessment phase revealed that only 7 of 14 centers had IPC protocols, and 8 centers provided IPC training for their staff. Furthermore, only 7 centers had medical protocols, and 5 used individualized hemodialysis prescriptions. Difficulties in testing for potassium was reported in 7 centers and the inability to perform hepatitis B and C serologies was reported in 3 centers. Only 2 centers adhered to machine and water treatment system maintenance guidelines, and 4 conducted daily water quality checks. Recommendations were formulated, and an action plan was developed for implementation in the second phase. The plan encompassed enhancements in IPC practices, medical protocols, record-keeping, laboratory testing, and equipment maintenance.

Conclusion

This project underscores that hemodialysis services in conflict-affected areas do not meet the standards for quality care. It emphasizes the necessity of implementing a comprehensive framework that engages relevant stakeholders in defining and upholding quality care, a model that should be extended to other protracted conflict-affected regions.

Transplantation in the Context of Migration and Refugees: A Summary of the DICG and TTS Ethics Committee Workshop, Buenos Aires, Argentina, September 2022

Global conflicts and humanitarian crises have resulted in an unprecedented number of refugees and migrants. This challenges the limited resources of health care systems and jeopardizes the availability of transplant care for these deserving migrants and refugees. This was the basis for a workshop held during the Congress of the Transplantation Society (Buenos Aires, 2022). We elaborate on the proceedings of the workshop entitled "Transplantation in the Context of Migration and Refugees," organized by the Ethics Committee of The Transplantation Society and Declaration of Istanbul Custodian Group. Transplant providers from around the world shared strategies of how each region has responded to providing access to care for refugees and migrants in need of transplant services. The potential exploitation of this vulnerable group leading to illicit organ removal was addressed for each region. The Transplantation Society, Declaration of Istanbul Custodian Group, and global transplant community should continue to focus on the status of refugees and migrants and collaborate on strategies to provide access to transplant care for this deserving population. Global cooperation will be essential to provide vigilant oversight to prevent exploitation of this vulnerable population.

Conflict Nephrology: War and Natural Disasters

Access to care for patients with ESKD is frequently disrupted after natural disasters, public health crises, and human conflict. Emergency preparation can mitigate the risk of harm and improve outcomes. Before Hurricane Katrina in 2005, the United States was unprepared to assist patients facing disaster. We evaluate responses to Hurricane Katrina which caused unprecedented damage to health and property in the Gulf Coast. As a result of the multitude of identified problems with the national, local, and kidney-specific responses to Katrina, new systems were created that mitigated loss after Hurricane Sandy in 2012. The improved disaster response system was no match for the coronavirus disease 2019 pandemic; real-time changes worsened the effect on highly vulnerable populations, including patients with ESKD. Similarly, preparation can only mitigate the difficulties faced by patients with ESKD living in a war zone. Government agencies need to provide tools and dialysis centers need to educate patients. Beginning with steps implemented in the aftermath of Hurricane Katrina and augmented after Hurricane Sandy, every patient with ESKD and those who care for them must begin emergency preparations before the need arises. Recognizing that it is not possible to prepare for every possible emergency, our health care systems must be ready to adapt to our ever-changing world. After reviewing the responses to previous events, we suggest steps that should be considered to improve preparations for our uncertain future.

Ethical Aspects of Kidney Donation and Transplantation for Migrants

Migrants represent a large and diverse population globally that includes international refugees, stateless persons, expatriate workers, and more. Many migrants face significant barriers in accessing health care, especially scarce and costly resources such as dialysis and kidney transplantation. Improving equity of access to these kidney replacement therapies for migrant populations may present a range of complex ethical dilemmas, particularly in the setting of crises and when considering the use of residency status and citizenship as eligibility criteria for access to treatment. In this article, we discuss ethical obligations to provide kidney care for migrants, the implications of the self-sufficiency concept with regard to access to deceased donation and transplantation, factors that may influence evaluation of the risks and benefits of transplantation for migrants with insecure access to care, and the vulnerability of migrants to organ trafficking. We also present a set of general recommendations to assist in preventing and managing ethical dilemmas when making decisions about policy or practice regarding kidney care for migrants.

Compounded trauma: A qualitative study of the challenges for refugees living with advanced cancer

BACKGROUND

Although palliative care is now an essential health service under Universal Health Coverage, ensuring access and appropriate care for refugees is a specific challenge for this large population.

AIM

To identify the needs and experiences of adult refugees in Jordan with advanced cancer and informal caregivers.

DESIGN

A qualitative study using semi-structured interviews.

SETTING/PARTICIPANTS

Participants were purposively sampled at two Jordanian hospitals to achieve heterogeneity by age, gender, country of origin, and primary diagnosis.

RESULTS

Twenty-nine refugees (22 patients, 7 caregivers) participated, and four themes were generated: (1) Psychological distress and sustaining social support. Refugees often experienced unmet psychosocial needs. However, psychosocial support was reported either absent or limited. (2) Knowledge and uncertainty. Lack of information and poor communication between healthcare providers and patients caused significant distress due to uncertainty. (3) Family anxiety and support roles. Being away from the home country cut patients and caregivers off from their wider social support network, which added increased anxiety and responsibilities to caregivers. (4) Compounded trauma and poverty. Many refugees have experienced trauma related to war that may affect their physical and mental health. They faced serious financial crises caused by the rising cost of medicines and treatment.

CONCLUSIONS

This study reveals the impact of fractured families and networks on social support in advanced cancer, and the compounding trauma of the disease for refugees. Detailed person-centred assessment and emphasis on psychosocial support is essential, and home-based care should not presume community support for patients to remain at home.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in the Middle East

Kidney failure is the permanent impairment of kidney function associated with increased morbidity, hospitalization, and requirement for kidney replacement therapy. A total of 11 countries in the Middle East region (84.6%) responded to the survey. The prevalence of chronic kidney disease in the region ranged from 5.2% to 10.6%, whereas prevalence of treated kidney failure ranged from 152 to 826 per million population. Overall, the incidence of kidney transplantation was highest in Iran (30.9 per million population) and lowest in Oman and the United Arab Emirates (2.2 and 3.0 per million population, respectively). Long-term hemodialysis services were available in all countries, long-term peritoneal dialysis services were available in 9 (69.2%) countries, and transplantation services were available in most countries of the region. Public funding covered the costs of nondialysis chronic kidney disease care in two-thirds of countries, and kidney replacement therapy in nearly all countries. More than half of the countries had dialysis registries; however, national noncommunicable disease strategies were lacking in most countries. The Middle East is a region with high burden of kidney disease and needs cost-effective measures through effective health care funding to be available to improve kidney care in the region. Furthermore, well-designed and sustainable health information systems are needed in the region to address current gaps in kidney care in the region.

Distribution and management of the pediatric refugee population with renal replacement: A German pediatric cohort

With migration rising, the pediatric nephrology community is faced with challenges concerning the management of end-stage kidney disease (ESKD) in the pediatric refugee population. Data on the care of the pediatric refugee cohort on renal replacement therapy (RRT) is not available. A survey conducted by us in 2018 showed that the group of refugee children arriving to Germany during the years 2015-2017 accounts for approximately 20% of the total pediatric dialysis population in Germany. Provision of (medical) care for these children and their families is often hampered by psychosocial problems, cultural differences, language barriers, and administrative issues. Treating centers need to provide additional human as well as financial and logistic resources. In this educational review, we raise awareness and discuss possible challenges occurring in the treatment of refugee children with ESKD.

Sustainable Development Goals relevant to kidney health: an update on progress

Globally, more than 5 million people die annually from lack of access to critical treatments for kidney disease — by 2040, chronic kidney disease is projected to be the fifth leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because they are pathologically diverse and are often asymptomatic. As such, kidney disease is often diagnosed late, and the global burden of kidney disease continues to be underappreciated. When kidney disease is not detected and treated early, patient care requires specialized resources that drive up cost, place many people at risk of catastrophic health expenditure and pose high opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress is disjointed and uneven among and within countries. The six SDG Transformations framework can be used to examine SDGs with relevance to kidney health that require attention and reveal inter-linkages among the SDGs that should accelerate progress.

Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease.

Each Sustainable Development Goal (SDG) has the potential to improve kidney health and prevent kidney disease by improving the general health and well-being of individuals and societies, and by protecting the environment.

Achievement of each SDG is interrelated to the achievement of multiple other SDGs; therefore, a multisectoral approach is required.

The global burden of kidney disease has been relatively underestimated because of a lack of data.

Structural violence and the social determinants of health have an important impact on kidney disease risk.

Kidney disease is the leading global cause of catastrophic health expenditure, in part because of the high costs of kidney replacement therapy.

Achievement of universal health coverage is the minimum requirement to ensure sustainable and affordable access to early detection and quality treatment of kidney disease and/or its risk factors, which should translate to a reduction in the burden of kidney failure in the future.

End-Stage Kidney Disease in Areas of Armed Conflicts: Challenges and Solutions

Violent and protracted conflicts are disastrous to civilian populations and their health care systems. The complex requirements of caring for end-stage kidney disease (ESKD) dialysis patients in such contexts pose unique challenges. Dialysis is procedurally complex and resource-intensive. Delivering ESKD care in man-made conflict settings presents added challenges beyond what is required in natural disasters and resource-limited situations. In this article, we review the medical literature on, and document experience with, managing dialysis ESKD patients in conflict zones. We discuss the impact of war on patient outcomes, dialysis system infrastructure, operational funding, and risks to providers and organizations. This article provides recommendations to health care providers, educators, and policymakers on how to mitigate associated challenges.

The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries

Human suffering as a result of natural disasters or conflict includes death and disability from non-communicable diseases, including diabetes, which have largely been neglected in humanitarian crises. The objectives of this Series paper were to examine the evidence on the burden of diabetes, use of health services, and access to care for people with diabetes among populations affected by humanitarian crises in low-income and middle-income countries, and to identify research gaps for future studies. We reviewed the scientific literature on this topic published between 1992 and 2018. The results emphasise that the burden of diabetes in humanitarian settings is not being captured, clinical guidance is insufficient, and diabetes is not being adequately addressed. Crisis-affected populations with diabetes face enormous constraints accessing care, mainly because of high medical costs. Further research is needed to characterise the epidemiology of diabetes in humanitarian settings and to develop simplified, cost-effective models of care to improve the delivery of diabetes care during humanitarian crises.

Kidney Transplantation Outcomes in Temporarily Protected Syrian Patients With End-Stage Renal Failure in Turkey

BACKGROUND

Approximately 6.3 million Syrian people migrated to other countries due to war since 2011. There are more than 3.5 million Syrian people living in Turkey under temporary protection. Syrian people receive free health care in Turkey, including kidney transplantation. Our institution started a kidney transplantation program about 3 years ago. It is the first institution performing living, related kidney transplantation for Syrian patients with end-stage renal failure.

METHODS

All living, related kidney transplantations to Turkish and Syrian patients from the beginning of our transplantation program until September 2018 were enrolled in this study. Donor and recipient characteristics, induction and maintenance immunosuppression, length of hospital stay, creatinine values at first week and first month, treatment incompatibility, and graft survival were evaluated.

RESULTS

Of the 25 living, related kidney transplantations 20% were Syrian. Three of 5 Syrian recipients were in the pediatric age group. None of the Syrian transplantations were preemptive, while half of the Turkish transplantations were preemptive (P = .005). Immunosuppression protocols, creatinine values, length of hospital stay, and graft survival rates were similar between groups. None of the Syrian recipients had treatment incompatibility (0%), unlike the Turkish recipients (15%).

CONCLUSION

Outcomes of kidney transplantation for Syrian recipients are similar to those of Turkish recipients. Having this no-cost facility is great for Syrian kidney failure patients. The number of transplantations for Syrian patients under temporary protection in Turkey is expected to increase in the future, with these favorable results and easy to access, free health care facilities.

Renal Failure Patients in Disasters

Disasters occur regularly, and frequently large numbers of patients treated with maintenance dialysis or with the recent onset of acute kidney injury are put at risk owing to the lack of access to dialysis care precipitating also a kidney failure disaster. The absence of necessary dialysis treatments can result in excessive emergency department visits, hospitalizations, morbidity, or an early death. Those with kidney failure are often evaluated in disaster medical locations or hospitals without nephrologists in attendance. Here we offer guidance for medical personnel evaluating such patients so that dialysis-dependent individuals can be properly assessed and managed with the need for urgent dialysis recognized. A disaster dialysis triage system is proposed. (Disaster Med Public Health Preparedness. 2019;13:782-790).

Hemodialysis Experience of a Large Group of Syrian Refugees in Turkey: All Patients Deserve Effective Treatment

BACKGROUND/AIMS

Refugee dialysis is a worldwide growing dilemma with limited experience. This report presents the largest hemodialysis (HD) patient registry data of Syrian refugees in Turkey.

METHODS

Demographic, clinical, laboratory, and dialysis practice data of 345 Syrian HD patients during one year were collected and analyzed.

RESULTS

There were 345 prevalent Syrian HD patients at the end of 2016. Majority of the patients were placed in the Southeast Anatolian Region. The majority of the patients (74.8%) are in the age range of 20-64 years. Dialysis vintage in Turkey is less than 12 months in 20.8% and less than one month in 29.3% of patients. The vascular access was arteriovenous fistula in the majority of patients (72.5%). Kt/V is over 1.7 in 57%, serum albumin is above 35 g/L in 65.8% and hemoglobin level is more than 100 g/L in %65.2 of the patients. The ratio of patients with serum phosphorus level of 1.13-1.77 mmol/L was 56.2%. Twenty Syrian HD patients (14 male, 6 female) died within the year 2016 and annual mortality rate was 5.7%.

CONCLUSION

This study with the largest number of Syrian refugees undergoing maintenance hemodialysis showed good dialysis practices, acceptable values for dialysis adequacy and biochemical parameters along with lower mortality compared to native HD population of Turkey. Longer follow up will enrich the knowledge related to care of refugee population in all over the world.