Disasters are characterized by a high incidence and poor outcomes of acute kidney injury (AKI). In addition, people across the entire spectrum of chronic kidney disease (CKD) -including those not receiving kidney replacement therapy and those with kidney failure (i.e., glomerular filtration rate <15 mL/min/1.73 m2 or treatment by kidney replacement therapy) are disproportionately affected because their care depends on advanced technology, specific medications, and experienced personnel. Disaster-related logistical challenges significantly amplify the risks. These risks can be reduced through effective preparedness that integrates an all-hazards framework with disaster- and disease-specific strategies, requiring coordinated readiness of healthcare facilities, providers, and patients. Consequently, disaster nephrology has emerged as a distinct area of expertise within nephrology. Emergency responses may vary depending on the type and severity of the disaster and may involve medical and/or surgical management of injuries, mental health support, nutritional interventions, and logistical coordination. However, the management of AKI and CKD-particularly those with kidney failure-is complex and may be associated with high rates of morbidity and mortality. Following disasters, affected individuals should be systematically assessed not only for disaster-related complications but also for previously undiagnosed kidney and non-kidney conditions. Education of patients with kidney disease to anticipate and manage medical and logistical challenges during disasters is essential. Integrating preparedness planning, patient education, and coordinated response strategies is critical to minimizing preventable kidney-related morbidity and mortality in disaster settings.

Disasters, whether natural or man-made, adversely impact patients with kidney diseases, particularly those reliant on dialysis or transplantation, due to disrupted health care systems and limited access to essential therapies. CKD affects approximately 10% of the global population, leaving millions vulnerable during catastrophes. Acute kidney injury is common in disasters, with crush-related acute kidney injury being the most recognized, although other etiologies also contribute. Lessons from past disasters such as earthquakes, hurricanes, and conflicts reveal critical gaps in preparedness and response. Key findings include the importance of early dialysis, efficient logistical planning, and international collaboration. For instance, the Marmara and Kahramanmaras earthquakes underscored the need for rapid hyperkalemia management in crush victims, whereas Hurricane Katrina highlighted the vulnerability of dialysis-dependent patients even in well-developed health care systems. Ethical dilemmas in resource allocation during crises demand transparent and equitable decision-making. This review synthesizes experiences to propose strategies for improving outcomes, including patient education on emergency protocols, enhanced disaster training for health care providers, and robust international partnerships. By applying lessons from past events, the global nephrology community can mitigate risks and improve survival for kidney patients during future disasters.

The number of forcibly displaced people worldwide continues to rise each year due to armed conflicts, human rights violations and natural disasters. Many others migrate in search of better living conditions. People with chronic kidney disease, particularly those requiring kidney replacement therapy, are especially vulnerable during displacement. Preparedness is crucial to minimize risks for these patients. Education and training provided in the pre-disaster period may raise patients' resilience and improve outcomes. Local or national kidney disaster relief task forces could help coordinate evacuation efforts and care for migrant patients, ensuring collaboration among stakeholders. While providing high-quality kidney care is essential, challenges such as healthcare costs, reimbursement issues, and social or cultural barriers may limit access in host countries. It is also critical to address the psychological needs of displaced people. Caring for displaced patients raises ethical concerns, leading to moral distress and burnout among healthcare providers. Collaborative efforts to address these challenges are essential to ensure the best outcomes for both displaced individuals and host countries.

Background:Although post-transplant diabetes mellitus (PTDM) is a common complication after kidney transplantation, there are few data on prevention, optimal screening, and treatment strategies. Methods:The European Renal Association's DESCARTES working group distributed a web-based survey to European transplant centres to gather information on risk assessment, screening procedures, and management practices for preventing and treating PTDM in kidney transplant recipients. Results:Answers were obtained from 121/241 transplant centres (50%) across 15 European countries. Screening practices for diabetes mellitus during the transplant work-up varied, with only 13% of centres using the recommended oral glucose tolerance test (OGTT) and 14% not screening at all. At transplantation, 19% of centres tailored the immunosuppressive regimen based on perceived PTDM risk, using strategies such as cyclosporin use or early steroid withdrawal. Fifty-two percent adopted strict glycaemic control with basal insulin in the first days post-transplant. Sixty-eight percent had defined screening protocols for early PTDM (45 days-6 months), primarily based on fasting glycaemia and/or HbA1c, while only a minority (7%) incorporated an OGTT. Changes in immunosuppression were considered by 41% in cases of early hyperglycaemia (<45 days) and by 58% in established PTDM (>45 days). Besides insulin therapy, dipeptidyl peptidase-4 (DPP4) inhibitors and metformin were most frequently used to manage early hyperglycaemia (<45 days) and PTDM (>45 days). The use of SGLT2 inhibitors and GLP-analogues increased >45 days post-transplantation. Conclusion:This European survey underscores the significant variation in PTDM prevention, screening, and treatment practices, emphasizing the imperative for more explicit guidance in approaching this complication.

In the current paper, we will focus on requirements to ensure big data can advance the outcomes of our patients suffering from kidney disease. The associated ethical question is whether and how we as a nephrology community can and should encourage the collection of big data of our patients. We identify some ethical reflections on the use of big data, and their importance and relevance. Furthermore, we balance advantages and pitfalls and discuss requirements to make legitimate and ethical use of big data possible.  The collection, organization, and curation of data come upfront in the pipeline before any analyses. Great care must therefore be taken to ensure quality of the data at this stage, to avoid the 'garbage in garbage out' problem and suboptimal patient care as a consequence of such analyses.  Access to the data should be organized so that correct and efficient use of data is possible. This means that data must be stored safely, so that only those entitled to do so can access them. At the same time, those who are entitled to access the data should be able to do so in an efficient way, so as not to hinder relevant research.  Analysis of observational data is itself prone to many errors and biases. Each of these biases can finally result in provision of low-quality medical care. Secure platforms should therefore also ensure correct methodology is used to interpret the available data. This requires close collaboration of a skilled workforce of experts in medical research and data scientists. Only then will our patients be able to benefit fully from the potential of AI and big data.

With the increasing frequency and severity of disasters and the increasing number of patients living with kidney disease, on dialysis and with transplants around the world, the need for kidney care in humanitarian settings is increasing. Almost all humanitarian emergencies pose a threat to kidney health because all treatments are highly susceptible to interruption, and interruption can be deadly. Providing support for people requiring dialysis in humanitarian settings can be complex and is associated with many trade-offs. The global kidney care community must become familiar with the ethics, principles and duties essential to meeting the overarching goals of ethical and effective disaster relief. Ethics principles and values must be considered on the individual, public health and global levels. The wellbeing of a single patient must be considered in the context of the competing needs of many others, and optimal treatment may not be possible due to resource constraints. Public health ethics principles, including considerations of triage and resource allocation, maximization of benefit and feasibility, often become directly relevant at the bedside. Individuals delivering humanitarian relief must be well trained, competent, respectful and professional, while involved organizations need to uphold the highest professional and ethical standards. There may be dissonance between ethical guidance and practical realities in humanitarian settings, which for inexperienced individuals may present significant challenges. Sustaining dialysis care in emergencies brings these issues starkly to the fore. Preparedness for dialysis in emergencies is an ethical imperative that mandates multisectoral stakeholder engagement and action, development of surge response plans, clinical and ethics guidance, and transparent priority setting. This manuscript outlines common ethics challenges and considerations that apply in all humanitarian actions, and illustrates their relevance to kidney care as a whole, using examples of how these may apply to dialysis and kidney disaster relief efforts in humanitarian settings.

PURPOSE OF REVIEW:Man-made and natural disasters become more frequent and provoke significant morbidity and mortality, particularly among vulnerable people such as patients with underlying kidney diseases. This review summarizes strategies to minimize the risks associated with mass disasters among kidney healthcare providers and patients affected by kidney disease. RECENT FINDINGS:Considering patients, in advance displacement or evacuation are the only options to avoid harmful consequences of predictable disasters such as hurricanes. Following unpredictable catastrophes, one can only rely upon educational initiatives for disaster risk mitigation. Preparatory initiatives before disasters such as training courses should target minimizing hazards in order to decrease morbidity and mortality by effective interventions during and early after disasters. Retrospective evaluation of previous interventions is essential to identify adverse consequences of disaster-related health risks and to assess the efficacy of the medical response. However, preparations and subsequent responses are always open for ameliorations, even in well developed countries that are aware of disaster risks, and even after predictable disasters. SUMMARY:Adverse consequences of disasters in patients with kidney diseases and kidney healthcare providers can be mitigated by predisaster preparedness and by applying action plans and pragmatic interventions during and after disasters. Preparing clear, practical and concise recommendations and algorithms in various languages is mandatory.

Each year, millions face natural disasters, encountering mass fatalities and severe medical issues such as crush injuries and crush syndrome. Crush syndrome, marked by acute kidney injury (AKI) and hyperkalemia, correlates with mortality. This study focuses on presenting epidemiological data on kidney disease resulting from the February 6, 2023 earthquakes centered in Kahramanmaras. This retrospective analysis included patients diagnosed with crush syndrome after the 2023 Kahramanmaras earthquakes, treated in regional hospitals or referred elsewhere in Turkey. Patient data were documented using the web-based system developed by the Turkish Nephrology Association Renal Disaster Working Group. Of the 1024 analyzed patients from 46 centers, 515 (50.3

Background: Early recognition and practical approaches for prevention and rapid treatment of acute kidney injury (AKI) is crucial for decreasing morbidity and mortality in earthquake victims. This study aims to determine various features of hospitalized crush syndrome patients with or without AKI after the Kahramanmara & scedil; (T & uuml;rkiye) earthquake in February 2023 and provides the knowledge of a tertiary referral center. Methods: Crush syndrome was described as the existence of crush injury and systemic manifestations. Patients without preexisting chronic kidney disease were diagnosed to have AKI in the presence of azotemia and/or increased creatinine levels ( > 2 mg/dl) with or without oliguria and hyperkalemia. Patients with crush syndrome were separated into 2 groups: group 1, AKI (+); group 2, AKI ( - ). Results: A total of 2300 earthquake wictims were admitted and compared with regards to the outcomes. After excluding 2147 patients, the final evaluation was performed in 153 patients (group 1, n = 56; and group 2, n = 97). Sepsis, hypovolemic shock, need for intensive care unit (ICU), and mortality rates were higher in AKI (+) patients than AKI ( - ). Thirty-four patients (22.2%) were admitted to the ICU, and 6 were non -survivors. One hundred forty-seven patients were discharged. Amputation, C -reactive protein (CRP), and each 50000 IU/L increase in creatine phosphokinase (CK) levels were risk factors for the development of AKI ( P < .05). Conclusion: Acute kidney injury in crush syndrome contributes to morbidity and mortality. Clinicians should be careful about AKI development in patients with amputation, high CRP, and CK levels > 50000.

This study investigated in-hospital outcomes and related factors in patients diagnosed with postearthquake crush syndrome after the earthquakes in Kahramanmaraş, Türkiye. One thousand twenty-four adult patients diagnosed with crush syndrome were analyzed. Data on demographic characteristics, clinical presentation, laboratory values, treatments, and outcomes were collected. A total of 9.8% of patients died during their hospital stay. Nonsurvivors were generally older, more likely to have preexisting chronic kidney disease, and faced more severe injuries and complications, including hypotension-shock, arrhythmias, elevated markers of renal dysfunction, and higher rates of acute kidney injury (AKI) and compartment syndrome. In addition, intensive care unit needs were higher. Multivariate analysis confirmed that age, injury severity, shock, high potassium, uric acid, and lactate levels on admission, development of AKI, compartment syndrome, and intensive care unit admission were significant predictors of mortality. Better disaster preparedness and improved health care infrastructure could be potential explanations for improved in-hospital mortality in the current era, as compared to previous earthquakes.

Transplantation is the optimal kidney replacement therapy; however, the shortage of donor organs is a major obstacle for its widespread use.Kidney transplantations from live donors are considered as an even more superior alternative.Live donors may be genetically related, or alternatively, may have emotional, social or legal relationships with the potential recipient.Rarely, however, none of these connections exists, and the donors are unrelated strangers, donating their kidney anonymously for altruistic reasons.

During conflicts, people with kidney disease, either those remaining in the affected zones or those who are displaced, may be exposed to additional threats because of medical and logistical challenges. Acute kidney injury developing on the battlefield, in field hospitals or in higher-level hospital settings is characterized by poor outcomes. People with chronic kidney disease may experience treatment interruptions, contributing to worsening kidney function. Patients living on dialysis or with a functioning graft may experience limitations of dialysis possibilities or availability of immunosuppressive medications, increasing the risk of severe complications including death. When patients must flee, these threats are compounded by unhealthy and insecure conditions both during displacement and/or at their destination. Measures to attenuate these risks may only be partially effective. Local preparedness for overall and medical/kidney-related disaster response is essential. Due to limitations in supply, adjustments in dialysis frequency or dose, switching between hemodialysis and peritoneal dialysis and changes in immunosuppressive regimens may be required. Telemedicine (if possible) may be useful to support inexperienced local physicians in managing medical and logistical challenges. Limited treatment possibilities during warfare may necessitate referral of patients to distant higher-level hospitals, once urgent care has been initiated. Preparation for disasters should occur ahead of time. Inclusion of disaster nephrology in medical and nursing curricula and training of patients, families and others on self-care and medical practice in austere settings may enhance awareness and preparedness, support best practices adapted to the demanding circumstances and prepare non-professionals to lend support.

Orthopedic injuries, especially fractures of long bones as well as multiple fractures and comminuted fractures, are very common after destructive disasters (e.g., earthquakes, wars, and hurricanes). Another frequent problem is traumatic rhabdomyolysis, which may result in crush syndrome, the second most frequent cause of death after direct traumatic impact following earthquakes. To improve outcomes, interventions should be initiated even before extrication of the victims, which include maintenance of airway patency and spine stabilization, stopping traumatic bleeding by any means, and initiating fluid resuscitation. On-site amputations have been extensively debated to liberate the victims if the release of trapped limbs is impossible. Early after the rescue, a primary survey and triage are performed, a fluid resuscitation policy is planned, complications are treated, the wounds are decontaminated, and the victim is transported to specialized hospitals. A triage and primary survey are also performed at admission to the hospitals, which are followed by a secondary survey, physical, laboratory, and imaging examinations. Washing and cleaning of the soft-tissue injuries and debridement in open, necrotic wounds are vital. Applications of fasciotomies and amputations are controversial since they are associated with both benefits and serious complications; therefore, clear indications should be defined. Crush syndrome has been described as the presence of systemic manifestations following traumatic rhabdomyolysis, the most important component of which is acute kidney injury that may contribute to fatal hyperkalemia. The overall mortality rate is around 20% in crushed patients, which underlines the importance of prevention. Treatment includes maintaining of fluid electrolyte and acid-base balance, application of dialysis, and also prevention and treatment of complications. The principles and practices in disaster medicine may differ from those applied in routine practice; therefore, organizing repeated training courses may be helpful to provide the most effective healthcare and to save as many lives as possible after mass disasters.

Abstract Background and Aims The Russian invasion on Ukraine, which started on 24th February 2022 led to migration of millions of people, including some of the about 10,000 adult dialysis patients. A Renal Disaster Relief Task Force (RDRTF) established by the European Renal Association, is dedicated to support the people living with kidney disease and to the nephrology community in Ukraine, working together with WHO, NGOs and industry. Besides these activities, the RDRTF conducted a survey to understand distribution and management of Ukrainian refugees requiring dialysis displaced to other European countries. The study aim was to characterize these patients and evaluate treatment modality and care they received after displacement. Method A cross-sectional online survey on status of displaced dialysis patients, clinical data and care they received after migration was sent to all national nephrology societies across Europe with a request to disseminate it to all dialysis centers in their countries. Data were collected between May and August 2022. Fresenius Medical Care (FMC) shared a set of aggregated data without direct center participation. Results Data on 602 patients (290 collected through the survey and 312 from FMC), who were dialyzed in 24 countries was gathered. Most patients were dialyzed in Poland (45.0%), followed by Slovakia (18.1%), Czech Republic (7.8%), Romania (6.3%), Germany (4.7%) and Hungary (3.5%). Mean time between last dialysis session and the first session in the reporting center was 3.1±1.6 days. For 28.1% of patients this time interval ranged from 4 to 12 days. Mean age was 48.1±13.4 years, and 43.5% of patients were females. The most common primary cause of kidney failure in the study group was glomerulonephritis or autoimmune diseases (29.5%), diabetic nephropathy constituted 12.7%. Before patients left Ukraine, 95.7% had been on hemodialysis, 2.5% on continuous ambulatory peritoneal dialysis (PD) and 1.8% on automated PD. Since leaving Ukraine, 33.8% of patients were hospitalized upon arrival at the reporting center. The most common causes of hospitalization were: anemia (18.6%), COVID-19 pneumonia (4.7%), non-COVID pneumonia (4.7%), overhydration (4.7%) and Perm-Cath implantation (4.7%), followed by exacerbation of heart failure, peripheral artery occlusive disease and arteriovenous fistula surgery. In terms of pharmacotherapy provided in the reporting dialysis units, 50.3% of patients received erythropoiesis stimulating agents and 36.9% received intravenous iron supplementation. 35.0%, 21.9% and 3.3% received phosphate binders, vitamin D analogues and cinacalcet, respectively. 29 patients (11.4%) were waitlisted for kidney transplantation (KTx) in Ukraine before displacement. Of these, 15 also qualified for KTx in the receiving country. A further 33 individuals who had not been listed for KTx in Ukraine, started the KTx recipient work-up under the care of the reporting center. Overall, 43 patients (17.4%) received psychological support – for 29 provided by the reporting dialysis units and for 14 patients outside the center. Conclusion Under 10% of dialysis patients fled Ukraine since the start of the Russian-Ukrainian war. Almost 30% of them remained without dialysis for 4 days or longer. Clinical status upon arrival often necessitated hospitalization. Our data indicate, that the treatment at receiving centers conformed with standard of care. Monitoring the situation of dialysis patients during armed conflicts may help in creating informed policies that allow for prompt and targeted interventions to respond to special needs of this vulnerable population.

Living donation challenges the ethical principle of non-maleficence in that it exposes healthy persons to risks for the benefit of someone else. This makes safety, informed consent (IC) and education a priority. Living kidney donation has multiple benefits for the potential donor, but there are also several known short- and long-term risks. Although complete standardization of IC is likely to be unattainable, studies have emphasized the need for a standardized IC process to enable equitable educational and decision-making prospects for the prevention of inequities across transplant centers. Based on the Three-Talk Model of shared decision making by Elwyn et al., we propose a model, named 3-Step (S) Model, where each step coincides with the three ideal timings of the process leading the living donor to the decision to pursue living donation: prior to the need for kidney replacement therapy (team talk); at the local nephrology unit or transplant center, with transplant clinicians and surgeons prior to evaluations start (option talk); and throughout evaluation, after having learned about the different aspects of donation, especially if there are second thoughts or doubts (decision talk). Based on the 3-S Model, to deliver conceptual and practical guidance to nephrologists and transplant clinicians, we provide recommendations for standardization of the timing, content, modalities for communicating risks, and assessment of understanding prior to donation. The 3-S Model successfully allows an integration between standardization and individualization of IC, enabling a person-centered approach to potential donors. Studies will assess the effectiveness of the 3-S Model in kidney transplant clinical practice.

Abstract Objectives The data of the monocyte subgroups and expressed toll like receptors (TLR) in the innate immune system response, which develop against chronic inflammation in patients with predialysis chronic kidney disease (CKD) and in patients who undergo dialysis treatment, are limited. We aimed to investigate the effect of the dialysis procedure on the current chronic inflammatory condition and which role of monocyte subgroups ratios, the expressions of TLR2/4 and serum Tumor necrosis factor alpha (TNF-α) levels involved in the innate immune response process. Methods We investigated monocyte subgroups, TLR2/TLR4 expressions and serum TNF-α levels in 30 predialysis CKD patients, 90 CKD patients undergoing dialysis and 30 healthy control subjects. Monocyte subgroup percentages and TLR2/TLR4 expressions were determined using the flow cytometry, serum TNF-α levels were investigated using the enzyme-linked immunosorbent assay (ELISA). Results In the dialysis patients, the percentages of classical (p=0.0001) and non-classical (p=0.078) monocytes were found to be higher when compared with the predialysis CKD patients. The percentages of TLR4 expression on non-classical monocytes was higher in dialysis and predialysis patients compared with the healthy controls (p<0.0001, p=0.796). Serum TNF-α level was significantly higher in dialysis and predialysis patients compared with the healthy controls (p=0.013, p=0.022) and a positive correlation between the classical monocyte subgroup and TNF-α was observed (r=0.285, p=0.006). Conclusions Increased percentages of non-classical monocytes, TLR4 expressions and serum TNF-α levels observed in the predialysis CKD patients and dialysis patients might be related to inflammation.

Crush syndrome (systemic manifestations of traumatic rhabdomyolysis) is the second leading cause of death after earthquakes or other destructive disasters. Crush-related acute kidney injury (AKI) is the most important component of crush syndrome, and medical professionals living in disaster-prone regions should know about its pathophysiology, clinical and laboratory features, complications, and treatment. Pathogenesis of AKI on the basis of crush injuries is multifaceted. The most important mechanism is compartment syndrome-related hypovolemia, and consequent renal hypoperfusion, which may result in ischemic acute tubular necrosis. Also, rhabdomyolysis-related myoglobinuria may result in the formation of kidney-damaging myoglobin casts and direct tubular toxicity. Formation of uric acid plugs, oxidant injury, increased serum levels of cytokines, and still many other factors may take a role in the pathogenesis as well. Crush syndrome can cause serious electrolyte imbalances, sepsis, and bleeding, which can further exacerbate AKI. Early recognition and appropriate management, which includes aggressive hydration and management of electrolyte imbalances can help to prevent or minimize kidney damage. This review provides an overview of the pathophysiology, complications, and treatment of AKI in the context of crush syndrome.

Patients with kidney disease, especially those with kidney failure, are particularly susceptible to the adverse effects of disasters because their survival depends on functional infrastructure, advanced technology, the availability of specific drugs and well-trained medical personnel. The risk of poor outcomes across the entire spectrum of patients with kidney diseases (acute kidney injury, chronic kidney disease and kidney failure on dialysis or with a functioning transplant) increases as a result of disaster-related logistical challenges. Patients who are displaced face even more complex problems owing to additional threats that arise during travel and after reaching their new location. Overall, risks may be mitigated by pre-disaster preparedness and training. Emergency kidney disaster responses depend on the type and severity of the disaster and include medical and/or surgical treatment of injuries, treatment of mental health conditions, appropriate diet and logistical interventions. After a disaster, patients should be evaluated for problems that were not detected during the event, including those that may have developed as a result of the disaster. A retrospective review of the disaster response is vital to prevent future mistakes. Important ethical concerns include fair distribution of limited resources and limiting harm. Patients with kidney disease, their care-givers, health-care providers and authorities should be trained to respond to the medical and logistical problems that occur during disasters to improve outcomes.