Most patients undergoing chronic, intermittent, in-center hemodialysis (HD) have a 2-day dialysis-free interval during which they are more vulnerable to developing volume overload, hyperkalemia, and other adverse outcomes. With this background, it is foreseeable that devastating natural disasters that interrupt the regular dialysis schedule would pose a threat to morbidity and mortality in End Stage Kidney Disease (ESKD) patients.
In a recent article published in AJKD, Lurie et al present a retrospective cohort analysis studying receipt of ‘early’ dialysis and adverse outcomes in 13,836 ESKD patients affected by Hurricane Sandy in the states of New York and New Jersey when it reached land on October 29, 2012. The authors carefully defined the delivery of ‘early’ dialysis in this cohort as treatment sessions scheduled a day or two earlier than usual, and found that 60% of ESKD patients underwent early dialysis. In this group, a statistically significant lower odds ratio of emergency department visits, early hospitalizations, and 30-day mortality was observed. The findings are noteworthy for the disparities in access to health care observed in non-white populations and those with inadequate health coverage.
Hurricane Sandy led to an unprecedented breakdown of medical services at our center in lower Manhattan. The New York Harbor VA Healthcare System hemodialysis unit was not included in the paper by Lurie et al, presumably because VA healthcare is not documented by Centers for Medicare and Medicaid Services. In anticipation of the hurricane, all inpatients with ESKD were transferred to the Brooklyn VA; the presence of an integrated health record system facilitated provision of timely medical services to these patients. We optimistically told our outpatient ESKD patients that they would miss one treatment on Monday or Tuesday, and then could report to our unit on Wednesday and Thursday. Instead, we spent the rest of the week trying to contact them and arrange for their dialysis at other facilities. We report here that none of our 45 patients died, and all missed at least 1 treatment or more. We learned a lot about emergency preparedness.
The authors have correctly pointed out that the presence of an emergency preparedness plan and coordination between health care facilities is necessary for provision of timely dialysis during natural disasters. The results of the study show that gaps exist in areas of emergency preparedness and patient education, as is evident from the fact that approximately 40% of ESKD patients did not receive early dialysis.
Through meticulous analysis of a large patient database, the authors have been able to make a strong case for provision of ‘early’ dialysis when major natural disasters are anticipated. However, this would entail significant resource investment, both in terms of money and manpower. On the other hand, a low event rate (5%) of primary outcomes in this study makes it necessary to conduct more studies in this area before a provision for ‘early’ dialysis can be made universal.
To conclude, we applaud the efforts of Lurie et al. in bringing to the foreground the issue of providing preemptive dialysis services to a medically fragile patient population with the potential to reduce patient morbidity and mortality.
– Post written by Dr. Sonika Puri, from the Department of Nephrology, M.S. Ramaiah Medical College, Bangalore, India and Dr. David S. Goldfarb, from the Division of Nephrology, New York University School of Medicine and NY Harbor VA Healthcare System, New York