Renal Crisis in Children during Armed Conflict Lale Sever, MD. * and Ayse Balat, MD † Summary: Armed conflicts continue to occur in some regions of the globe, mostly in developing countries. These man-made disasters affect all segments of the population; however, some groups are more vulnerable and suffer more seriously from the unfavorable consequences of such conflicts. Among these, the pediatric population deserves special attention because they cannot protect themselves, and hence carry a higher threat of injuries and probability of death during conflicts. In addition, children who do survive the disaster are more prone to exploitation. Pediatric victims, including those who sustain acute kidney injury or those suffering from chronic kidney disease before armed conflicts, face higher risks of morbidity and mortality as a result of treatment problems, specifically lim- ited dialysis options. Displaced children, forced to flee their homes as a result of armed conflicts, are also at risk for various health problems because they may not find ideal circumstances for disease treatment. Making preparations in anticipation of armed conflicts, such as disaster-relief scenarios and action plans, may be useful to decrease the death toll in these children, who are dependent on their caregivers for survival. Adopting principles of disaster nephrology may contribute to improved survival chances of pediatric kidney patients in chaotic circumstances. Semin Nephrol 40:408-420 Ó 2020 Elsevier Inc. All rights reserved. Keywords: Armed conflict, children, kidney disease, pediatric victim, acute kidney injury D isasters may be either natural or human in origin. Earthquakes, tsunamis, and hurricanes are typi- cal examples of natural disasters, whereas wars, terrorist attacks, political repression, religious conflicts, persecution, and poverty are among the most important anthropic (or man-made) disasters. 1 Disasters profoundly disrupt the functioning of a soci- ety and result in widespread human, material, economic, and environmental losses. Recently, the number and dimensions of man-made disasters (especially armed conflicts) have been gaining more importance, especially in some regions of the world. Children are an important risk group in armed conflicts. Unfortunately, sometimes they are not affected acciden- tally, but rather directly targeted by combatants. 2 Beyond that, living conditions become suboptimal during con- flicts, thus children cannot find a suitable environment for optimal development. They also may suffer from the loss of their caregivers. As a result, they are faced with a sig- nificant risk of conflict-related morbidity and mortality. In this review, we discuss the effects of armed con- flicts on the overall health of children, followed by com- ments on kidney problems in the pediatric population during armed conflicts. THE EFFECTS OF ARMED CONFLICT ON THE OVERALL HEALTH OF CHILDREN ARMED CONFLICT AS A DISASTER The New Humanitarian Group (formerly the Integrated Regional Information Networks news) reported that in April 2017, more than 40 active conflicts ensued around the world. 3 Although Syria, Afghanistan, and Iraq are well known by the international community because of the media or policy attention, “unrecognized or forgotten wars” also are ongoing around the globe (Fig. 1). Exam- ples include, but are not limited to, decades-long con- flicts from Colombia to the Ogaden, from Kashmir to Western Sahara, and conflicts in Myanmar, Casamance, South Kordofan, Southern Thailand, and Mindanao in the Philippines. A report from Save the Children 4 under- lines that the number of children living in conflict- affected zones is increasing. It is noteworthy that all of these are low-income and developing countries. During the 20th century, the proportion of civilian victims from wars and conflicts had increased steadily from 66% in World War II to almost 90% by the end of the 1980s. 5 This was partly owing to the increased lethal- ity of weapons technology. Today, aerial bombardment and chemical weapons have extended the potential battle zone to entire national territories. A further cause of the increasing death toll for civilians is that most contempo- rary conflicts are not between states, but within civilian groups. Families, women, and children are targeted indiscriminately or sometimes intentionally during many conflicts. The statistics Unfortunately, globally, nearly 1 in 10 children live in regions affected by armed conflicts, 6 which translates *Department of Nephrology, Istanbul University-Cerrahpasa, Cer- rahpasa School of Medicine, Department of Pediatric Nephrology, Istanbul, Turkey yIstanbul Aydin University, School of Medicine, Department of Pedi- atric Nephrology and Rheumatology, Istanbul, Turkey Financial disclosure and conflict of interest statements: none Address reprint requests to Lale Sever, MD, Department of Pediatric Nephrology, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, 34098, Turkey. E-mail: severlale@hotmail.com 0270-9295/ - see front matter © 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.semnephrol.2020.06.008 408 Seminars in Nephrology, Vol 40, No 4, July 2020, pp 408-420