What are the emergency management strategies for hemodialysis patients during disaster situations?

Emergency Disaster Preparedness in Hemodialysis

Pre-Disaster Preparation for Dialysis Facilities

Dialysis facilities must establish comprehensive disaster plans that include identification of partner renal units, backup power and water systems, communication protocols that function without telephone/Internet, and staff training—with regular rehearsals required by U.S. regulations. 1

Infrastructure Requirements

• Secure dual water supply systems, as water supply failure is the leading cause of dialysis treatment malfunction after earthquakes; facilities should install well water backup systems with double piping circuits to ensure continuous dialysis capability 2, 1
• Install emergency generators with sufficient capacity to power dialysis machines, as most standard emergency generators cannot power all patient rooms adequately; pre-arrange contracts for temporary generators with appropriate adaptors 3, 1
• Maintain dialysis equipment stockpiles including portable hemodialysis machines that can be rapidly deployed, as these machines should be left in disaster zones rather than transported back after relief efforts 1

Facility Coordination and Planning

• Establish formal partnerships with alternative dialysis facilities in different geographic regions to enable patient transfers within 48-72 hours maximum, as delays beyond this timeframe significantly increase hospitalization and mortality 1, 4
• Develop communication systems that function without standard infrastructure, recognizing that telephone and Internet services will be disrupted; consider web-based inventories of specialty services with contact numbers when mobile networks are available 1
• Create detailed coordination protocols with emergency departments, critical care units, and local emergency management agencies for patient evacuation and resource allocation 3, 1

Pre-Disaster Preparation for Patients

Hemodialysis patients must maintain portable waterproof medical documentation, secure a minimum 7-14 day emergency medication supply, identify alternative dialysis facilities, and understand the renal emergency diet emphasizing potassium and fluid restriction. 4, 1

Essential Patient Preparations

• Carry waterproof copies of complete medical records including current medications, dosages, dialysis treatment schedules (frequency, duration, ultrafiltration goals), recent laboratory values, and vascular access details at all times 4, 1
• Stockpile 7-14 days of essential medications in waterproof, portable containers including antihypertensives, phosphate binders, erythropoiesis-stimulating agents, and any immunosuppressants for transplant patients 4, 1
• Receive education on the renal emergency diet with strict potassium restriction (<2000 mg/day) and fluid limitation (500-1000 mL/day depending on residual urine output), as patients may go several days without dialysis during relocation 4, 5
• Establish evacuation plans similar to those provided by the National Kidney Foundation, with identified alternative facilities and transportation arrangements updated annually 1, 4

Immediate Post-Disaster Response (0-72 Hours)

The absolute priority is transferring dialysis-dependent patients to functioning facilities within 48-72 hours maximum, as delays beyond this timeframe cause life-threatening hyperkalemia, fluid overload, and uremia with significantly increased mortality. 4, 5

Patient Triage and Transfer

• Implement immediate patient location and assessment systems to identify all dialysis-dependent patients in the disaster zone within the first 24 hours 1, 3
• Prioritize emergency dialysis for patients with absolute indications: severe hyperkalemia (>6.5 mEq/L) with ECG changes, pulmonary edema unresponsive to diuretics, severe metabolic acidosis (pH <7.2), uremic encephalopathy, or uremic pericarditis 5, 1
• Arrange patient evacuation to functioning facilities through coordination with local and national agencies when local dialysis capacity is destroyed or overwhelmed 1

Temporizing Medical Management

• Provide potassium-binding resins (sodium polystyrene sulfonate) to all dialysis patients who cannot access treatment immediately to prevent life-threatening hyperkalemia 4, 5
• Implement strict fluid restriction protocols limiting intake to 500-1000 mL per day depending on residual urine output for patients awaiting dialysis 4, 5
• Establish emergency medication distribution systems at shelters within 24-48 hours, as patients are at extremely high risk for decompensation without antihypertensives, diuretics, and other critical medications 4, 1

Dialysis Operations During Disasters

Intermittent hemodialysis is the preferred modality during disasters due to rapid potassium clearance, ability to treat multiple patients per machine daily, and minimal anticoagulation options—though treatment duration may need limitation when patient numbers exceed capacity. 1

Treatment Modality Selection

• Prioritize intermittent hemodialysis as it provides rapid clearance of potassium (critical in hypercatabolic crush injury patients), allows treatment of several patients per day on the same machine, and offers options for minimal anticoagulation in bleeding-prone trauma patients 1
• Reserve continuous renal replacement therapy for hemodynamically unstable patients only, as it requires 24/7 nursing care that may not be available in disaster zones 1, 5
• Consider peritoneal dialysis as an alternative in small children or when hemodialysis is unavailable, though rapid exchanges with high-glucose solutions are required for adequate potassium removal and ultrafiltration 1

Treatment Protocols and Rationing

• Provide one or more dialysis treatments per day for crush injury patients due to their hypercatabolic state requiring aggressive potassium control 1
• Limit treatment duration for both acute kidney injury and chronic dialysis patients when patient numbers exceed capacity or equipment availability, though this is not ideal 1
• Establish clear rationing protocols through a Central Triage Committee when dialysis machines and staff are insufficient for patient volume, balancing treatment of crush injury victims with ongoing care for chronic dialysis patients 1, 3

Water Supply Management

• Secure suitable water supply immediately, as this is the major challenge in providing intermittent hemodialysis in disaster zones; dialysis technicians should liaise with other volunteers (firefighters) to provide appropriate water 1, 2
• Utilize point-of-care devices (iStat) for laboratory monitoring when standard infrastructure is unavailable, though these devices have narrow operational temperature ranges (16-30°C) and must be kept in temperature-controlled containers 1

Management of Crush Injury and Acute Kidney Injury

Early aggressive fluid resuscitation with 0.9% saline at 1 L/hour should begin before extrication of crush victims, as this narrow time window is critical to prevent myoglobinuric acute kidney injury and oliguria. 1, 5

Fluid Resuscitation Protocol

• Insert intravenous access or intraosseous needle as soon as the victim is located, before extrication efforts are complete 1
• Infuse 0.9% saline at 1 L/hour during extrication; if extrication exceeds 2 hours, reduce infusion rate to ≥0.5 L/hour 1
• Continue aggressive fluid resuscitation after extrication with 3-6 liters IV depending on clinical condition and response, monitoring for 6 hours from initiation 1
• Avoid sodium bicarbonate and mannitol in mass disaster settings, as bicarbonate may worsen hypocalcemia and mannitol provides little extra benefit compared to crystalloids alone while being potentially nephrotoxic and requiring close monitoring that is impossible after disasters 1

Dialysis Timing and Indications

• Initiate dialysis earlier in crush-related AKI compared to other causes, as life-threatening complications (acidosis, hyperkalemia, fluid overload) are more frequent and may necessitate more frequent dialysis 1, 5
• Monitor for acute compartment syndrome requiring fasciotomy when intracompartment pressures are ≥20 mm Hg in hypotensive patients or ≥30 mm Hg in normotensive patients with positive clinical findings 1

Logistics and International Response

The International Society of Nephrology's Renal Disaster Relief Task Force deploys advance response teams to assess and implement fluid and dialysis treatment, sending necessary manpower and materials in rapid succession, with support from Médecins Sans Frontières. 1

Response Team Composition and Deployment

• Deploy experienced volunteers initially in teams combining prior disaster experience with newcomers, including nephrologists, intensivists, dialysis nurses, and dialysis technicians 1
• Limit volunteer deployments to 10-14 days maximum due to challenging conditions with long work hours, sparse accommodation, and considerable psychological stress 1
• Ensure volunteers are immunized against tetanus, hepatitis A and B, and ideally fluent in French or Spanish for international deployments 1

Timeline and Disengagement

• Expect most crush-related AKI cases within 1 week after earthquakes; patients presenting after 10 days typically have early-stage chronic kidney disease with deterioration from dehydration or sepsis 1
• Leave hemodialysis machines in local renal units rather than transporting them back after relief efforts conclude 1
• Coordinate through United Nations Office for the Coordination of Humanitarian Affairs to harmonize activities between relief agencies and governmental bodies 1

Critical Pitfalls to Avoid

• Never delay fluid resuscitation waiting for extrication to be complete in crush victims, as the narrow time window for preventing acute kidney injury closes rapidly 1
• Avoid transporting large amounts of peritoneal dialysis supplies without confirmed local capacity to use them, as occurred in Haiti where supplies were never utilized 1
• Do not underestimate water requirements for dialysis operations, as water supply failure is the leading cause of treatment malfunction; inform politicians and water departments that dialysis requires massive water volumes 2, 1
• Never allow inadequate medication stockpiling (less than 7 days supply) by patients, as pharmacy access may be impossible for 1-2 weeks and treatment gaps cause dangerous decompensation 4
• Avoid delaying patient relocation beyond 72 hours for dialysis-dependent patients, as this significantly increases hospitalization and mortality risk 4