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).

Improvement of hemodialysis catheter function with tenecteplase: a phase III, open-label study: TROPICS 4.

Hemodialysis (HD) catheters are prone to thrombotic occlusion. We evaluated tenecteplase, a thrombolytic, for the treatment of dysfunctional HD catheters. Patients with tunneled HD catheters and blood flow rate (BFR) <300 mL/min received open-label tenecteplase (2 mg/lumen) for a 1 h intracatheter dwell. Treatment success was defined as BFR ≥ 300 mL/min and a ≥ 25 mL/min increase from baseline BFR, 30 min before and at the end of HD. Patients without treatment success at the end of the initial visit received another 2 mg dose of tenecteplase for an up to 72 h extended dwell. Of 223 enrolled patients, 34% (95% confidence interval [CI], 28-40%) had treatment success after a 1 h dwell. Mean (standard deviation [SD]) BFR change from baseline was 82 (124) mL/min. Treatment success in those who received extended-dwell tenecteplase (n = 116) was 49% (95% CI, 40-58%), with mean (SD) BFR change from baseline of 117 (140) mL/min. Reported targeted adverse events included five catheter-related bloodstream infections and one thrombosis. No intracranial hemorrhage, major bleeding, embolic events, or catheter-related complications were reported. Tenecteplase administered as a 1 h or 1 h plus extended dwell was associated with improved HD catheter function in the TROPICS 4 trial.

Kidney patient care in disasters: emergency planning for patients and dialysis facilities.

The catastrophic 2005 hurricane season alerted Americans to the need for a more effective response to mass casualty incidents. To address the needs of the nephrology community, the Kidney Community Emergency Response Coalition (KCERC) was formed, with representatives from more than 50 governmental agencies and private organizations. After completing phase 1 of its work, the KCERC issued recommendations for patients, dialysis units, and providers. During phase 2, the KCERC will promote implementation of those recommendations. During a disaster, the KCERC will host a daily conference call on which dialysis facilities, the End-Stage Renal Disease Networks, and emergency response officials will coordinate disaster response. Predisaster preparation for kidney patients should stress identification of alternative dialysis facilities, education about the renal emergency diet, and plans for early evacuation from the disaster area and for evacuating with medical documents and medications. Dialysis facilities are required to have a disaster plan; regular revision and rehearsal are essential. Critical issues for dialysis facilities include identification of partner facilities, a robust communications plan that takes into account the limitations of telephones and broadband access, staff shortages in the face of a possible influx of new patients, the delivery of service in the face of compromised utilities (water, power), and the recovery of a dialysis facility that experiences flooding or structural damage. A timeline to safety for dialysis patients can be visualized; if specific tasks are accomplished at each disaster stage, then it is likely that the health of these vulnerable patients can be protected.

Kidney patient care in disasters: lessons from the hurricanes and earthquake of 2005.

The active 2005 hurricane season alerted Americans to the pressing need for a more effective response to mass casualty incidents. The kidney patient community was particularly affected. Ninety-four dialysis facilities in the Gulf Coast states closed for at least 1 wk in the aftermath of Hurricane Katrina, and additional units were affected by evacuation of dialysis patients. Dialysis units along the Gulf Coast were also affected by Hurricanes Rita and Wilma. Existing emergency response plans were inadequate in providing continuity of care for kidney patients. The Kashmir, South Asia, earthquake of October 2005 killed 97,000 individuals. Building collapse was associated with widespread crush injury, and many patients required temporary hemodialysis. Several regions of the United States have the potential for catastrophic earthquakes. The Kidney Community Emergency Response Coalition has recently issued recommendations for patients, dialysis facilities, and providers, with a goal to improve care of kidney patients in future domestic disasters. With suitable planning, the nephrology community can do much to ensure the continuity of medical care for kidney patients in the face of a wide range of possible natural and human-made disasters.