Akram Al-Makki, A Oussama RifaiLina MuradAbdul R Zanabli, Anas Kayal, Khaldoun SoudanMazen Kherallah, Fahd Alsaghir, and Mohamed Sekkarie

Before the development of acute hemodialysis, mortality rate of acute renal failure (ARF) approached 100% in World War II.[1] Most of these kidney injuries were caused by crush injuries as described by Bywaters and Beall. The use of hemodialysis was first described in military services during the Korean War in 1950 for renal military casualties; this has led to a decline in mortality rate from around 90% to 53%.[2,3] Early intervention could prevent the occurrence of ARF, at least in military casualties.[4] During disasters and War situations, the delivery of healthcare services including hemodialysis can be interrupted due to destruction of medical facilities and infrastructure, lack of healthcare personnel, shortage of equipment and supplies, and interruption of electricity and water. The conduction of hemodialysis can also be interrupted by technical or electrical issues such as electrical power blackouts.[5]

The uprising demand for political change in Syria that started from March 2011 has marked the beginning of an ongoing Syrian political and humanitarian crisis. This conflict has led to a significant decline of living standards, loss of healthcare facilities, flight of medical personnel, severe shortage of medicines, lack of essential supplies and an increased risk of infectious diseases in the affected areas. According to the World Health Organization (WHO), the crisis context has compromised the provision of primary and secondary healthcare, the referral of injured patients, treatment of chronic diseases, disruption of maternal and child health services, vaccination and nutritional programs and that of communicable disease control.[6]

Renal care and hemodialysis patients were not the exception. The complexity and the requirements of the hemodialysis procedure magnified the problem in delivering quality, effective and safe services. All or some components of renal care were inadequate or completely absent due to security issues, unavailability of supplies, interruption of water and electricity, absence of maintenance and support, and absence of equipment and essential materials. Accurate figures are lacking due to scarce and limited data from the area and most of the information is based on direct observation and rare reports.

Many medical relief efforts were organized by non-governmental organizations (NGOs), including the Syrian American Medical Society (SAMS), to provide medical and psychological support to the internally displaced people, people in conflict-affected areas and Syrian refugees in surrounding countries.[7] Among the different medical missions of Syria, SAMS was the mission of the Syrian American Nephrologists to refugee camps and Northern Syria with the objective of providing a preliminary assessment of the care delivery status of renal patients. Their direct observation revealed that the care of dialysis patients was severely compromised due to lack of access to dialysis units, electricity outage, lack of medications and equipment, destruction of healthcare facilities and shortage of medical care providers. The majority of dialysis facilities had no supervising nephrologists; some of the provinces lacked the existence of any nephrologist. The majority of ARF was caused by crush injuries and rhabdomyolysis (54%) followed by gunshot injury (35%) per the observation of one of SAMS physicians who visited northern Syria. Mortality figures were not available due to destruction of information system and lack of any data collection, many deaths occurred in fields due to massive hemorrhage, crush injuries and the lack of appropriate resuscitation. Victims who survived the initial shock have developed ARF-acute kidney injury (AKI) and most of them died because of complications of ARF-AKI since renal replacement therapy (RRT) was not available. Some renal transplant patients had rejection and ended up on dialysis because of inability to find or afford anti-rejection medications.

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