Features of Chronic Hemodialysis Practice after the Marmara Earthquake MEHMET SUKRU SEVER,* EKREM EREK, † RAYMOND VANHOLDER, ‡ AYKUT KALKAN, § NEVIN GUNEY,  NESRIN USTA, ¶ CEVDET YILMAZ, # CAVIT KUTANIS,** RAMAZAN TURGUT, †† and NORBERT LAMEIRE ‡‡ *Renal Disaster Relief Task Force of the International Society of Nephrology and Department of Nephrology, Istanbul School of Medicine, Istanbul, Turkey; † Department of Nephrology, Cerrahpasa School of Medicine, Istanbul, Turkey; ‡ Renal Disaster Relief Task Force, Renal Division, University Hospital, Ghent, Belgium; § Belediye Dialysis Center, Izmit, Turkey;  Nefromed Dialysis Center, Adapazari, Turkey; ¶ State Hospital Dialysis Center, Izmit, Turkey; # State Hospital Dialysis Center, Yalova, Turkey; **Maruf Dialysis Center, Izmit, Turkey; †† State Hospital, Dialysis Center, Karamürsel, Izmit, Turkey; and ‡‡ Renal Disaster Relief Task Force European Branch, University Hospital, Ghent, Belgium Abstract. After disasters, treatment of chronic hemodialysis (HD) patients is problematic because of logistic and medical reasons. This study analyzes features of HD practice in the regions affected by the Marmara earthquake that struck north- western Turkey in August 1999. Questionnaires asking about HD infrastructure, medical/social problems of chronic dialysis patients, and the fate of dialysis personnel after the disaster were sent to dialysis units located in the affected region. Data gathered from eight HD centers that responded to question- naires were then analyzed. The number of HD centers and machines were 12 and 124, respectively, before the earthquake. The number of weekly HD sessions in the analyzed eight centers declined from 1093 before the disaster to 520, 616, and 729 1 wk, 1 mo, and 3 mo after the earthquake, respectively. In the effective seven centers, the number of HD personnel was 112 before the earthquake, which dropped to 86 and 94 1 and 3 mo after the disaster, respectively. Overall, there were 439 patients in the analyzed eight centers before the disaster, whereas data were provided on 356 (212 were male; mean age, 47.6  15.1 yr) dialysis patients. Six patients died, and seven were seriously and 28 mildly injured by the direct effects of trauma. The percentage of patients who received once-weekly dialysis increased from 2.3 to 7.2% within the first week, with a return to lower figures (4.1 and 2.8%) 1 and 3 mo afterward. Despite a decrease in the number of HD sessions, interdialytic weight gain decreased 1 wk after the disaster and BP measure- ments did not change significantly before and after the earth- quake. A total of 301 and 31 patients left their dialysis centers, temporarily and permanently. After catastrophic earthquakes, despite a decrease in the number of HD sessions, patients comply with disaster conditions, likely by strictly following dietary and fluid restrictions. Major earthquakes cause morbidity and mortality not only by the direct impact of trauma but also by interfering with the treatment of patients who have chronic diseases such as diabetes, hyperten- sion, chronic obstructive pulmonary disease, and end-stage renal disease (ESRD) (1– 4). Among these, chronic hemodialysis (HD) patients deserve special mention for various reasons: 1. HD practice is almost always performed in hospitals or in dialysis units, which can be damaged by the earthquakes (2,5,6). 2. Dialysis is a complex procedure that requires urban facili- ties such as water, electricity, and communication possibil- ities, which are also prone to be damaged by disasters. 3. Disposable dialysis items (dialyzers, lines, needles, concen- trates) may be destroyed or lost, and distribution of these items may be problematic as a result of transportation problems. 4. Acute renal failure as a result of crush syndrome is very frequent after disasters (7), and these patients also need dialysis; thus, the capacity of the dialysis facilities can be overwhelmed. 5. Dialysis personnel and their families are prone to be victims of the disaster themselves (5,8); hence, available facilities may not always work efficiently. Therefore, problems in maintaining regular treatment of chronic dialysis patients may result in fatal complications, especially as a result of hyperkalemia and volume overload (5). All of these issues were considered by the Turkish neph- rologists during the catastrophic Marmara earthquake that struck northwestern Turkey on August 17, 1999. According to the official reports, the disaster caused 17,480 deaths and 43,953 wounded (9); locally estimated mortality was even higher. Approximately 600,000 people became homeless, be- Received September 30, 2003. Accepted January 14, 2004. Corresponding to Dr. Mehmet Sukru Sever, Istanbul School of Medicine, Department of Nephrology, Çapa, 34390, Istanbul, Turkey. Phone: xx90-212- 4142512; Fax: xx90-212-4142028; E-mail: severm@hotmail.com 1046-6673/1504-1071 Journal of the American Society of Nephrology Copyright © 2004 by the American Society of Nephrology DOI: 10.1097/01.ASN.0000119145.40232.67 J Am Soc Nephrol 15: 1071–1076, 2004