ESKD Patients at Increasing Risk
The incidence and prevalence of chronic kidney disease (CKD) are on the upswing, leading to increasing morbidity and mortality.Reference Kalantar-Zadeh, Jafar and Nitsch 1 –Reference Lv and Zhang 3 Patients living with end-stage kidney disease (ESKD) represent a medically high-risk patient (MHRP) population facing escalating threats from climate change and compounding disasters.Reference Smith, Zucker and Frasso 4 –Reference Blum, Feng and Anderson 7 Among the more than 800 000 US patients who have a diagnosis of ESKD, our discussion focuses primarily on about 500 000 patients who rely on in-center hemodialysis, the most common dialysis modality. 8 These patients typically require hemodialysis 3 times weekly to effectively manage their ESKD and minimize complications. Interruptions to their hemodialysis regimens may adversely affect the health of patients with ESKD, leading to increased emergency department visits and hospitalizations, while extended treatment disruptions may be life-threatening.Reference Kopp, Ball and Cohen 5 , Reference Kopp, Ball and Cohen 6 , Reference Al Salmi, Larkina and Wang 9 –Reference Saran, Bragg-Gresham and Rayner 12
This research examines how increasing population exposures to extreme heat and climate-driven hurricanes jeopardize the health of patients with ESKD. We describe how climate disasters are not singular, circumscribed incidents, but rather multi-hazard clusters of compounding events that disproportionately threaten the survival of patients with ESKD. This is particularly timely because of the rise in compounding disasters as highlighted in the 5th National Climate Assessment, indicating that “climate change is increasing the chances of multiple climate hazards occurring simultaneously or consecutively across the US and its territories.” 13 This documented rise in compounding disasters does not just reflect an increased frequency of hazard events, but also the interaction among diverse, co-occurring or rapidly-sequential, disruptive events that will exacerbate harm, and complicate recovery. Safeguarding patients with ESKD and a host of other MHRP populations will become more challenging as climate threats worsen.
Using the case example of Hurricane Ian (an extreme event that combined the hazards of a Category 5 tropical cyclone, a massive power outage/ blackout, and a heatwave), we illustrate how kidney dialysis providers and emergency response coalitions are devising strategies and systems for safeguarding dialysis-dependent patients with ESKD during disasters.
Escalating Threats to Kidney Health From Climate Change-Triggered Patterns of Extreme Heat
Climate change is a significant driving force behind relentlessly rising global temperatures and increasing trends in regional heatwaves.Reference Perkins-Kirkpatrick and Lewis 14 Extreme heat is a potentially health-compromising and life-threatening hazard, 15 , Reference Ebi, Capon and Berry 16 to which healthcare systems must adapt.Reference Patel, Conlon and Sorensen 17 Patel and colleagues,Reference Patel, Conlon and Sorensen 17 have described how climate change and specifically extreme heat events, can massively overload health services by creating an influx of patients with heat illness, and exacerbation of chronic medical conditions, including chronic kidney disease, and ESKD.
The proliferation of population exposures to extreme heat, both independently and combined with other climate-driven emergencies, represents a compelling concern for nephrologists.Reference Sasai, Roncal-Jimenez and Rogers 18 The kidney is a target organ for heat stress and dehydration.Reference Sasai, Roncal-Jimenez and Rogers 18 Heat stroke is defined as a pathologic increase in core body temperature,Reference Sasai, Roncal-Jimenez and Rogers 18 and environmental heat stroke, exertional heat stroke, and to a lesser extent, other heat-related illnesses, can produce electrolyte disturbances, and acute kidney injury, as well as chronic kidney disease (CKD).Reference Sasai, Roncal-Jimenez and Rogers 18 Extreme heatwaves are disasters that are detrimental, and potentially deadly, for patients with CKD, or ESKD.
In 2023, populations around the globe sweltered through the most intense heat in modern records (Figure 1). Vast atmospheric “heat domes” formed, persisted, and threatened health and wellbeing for millions who were trapped beneath these weather systems.MHRPs, including those with ESKD, were at elevated risk of heat stroke. The superheated conditions during 2023 were a continuation of recent climate trends, and not an exception. The preceding consecutive years, 2015 through 2022, had been the warmest on record, 19 and 2023 surpassed them all, setting hundreds of global daily air and ocean heat records (Figure 1).
Figure 1. Daily sea surface temperature, World, 1981 through February 9, 2024.
Source: Birkel SD. ‘Daily Sea Surface Temperature,’ Climate Re-analyzer (https://ClimateReanalyzer.org), Climate Change Institute, University of Maine, USA. Available at: https://climatereanalyzer.org/clim/sst_daily/. Accessed February 10, 2024.
Borg and colleagues predicted that climate change would produce global increases in incidence and prevalence of kidney disorders through the effects of rising ambient temperatures, leading to heat stress and acute kidney injury (AKI).Reference Borg, Bi and Nitschke 20 , Reference Borg and Bi 21 AKI can be produced by extreme heat exposure through the induction of rhabdomyolysis and systemic inflammation. Repeated episodes of AKI may produce CKD, potentially progressing to ESKD (and in the reverse, patients with CKD are at increased risk for episodes of AKI).Reference Borg, Bi and Nitschke 20 , Reference Borg and Bi 21
Amid the heatwaves in 2023, Gallagher and colleagues,Reference Gallagher, Smyth and Jha 22 summarized the interrelationship between heat stress, and kidney health, noting the reciprocal interplay between AKI and CKD.Reference Coca, Singanamala and Parikh 23 , Reference Sykes, Asar and Ritchie 24 Multiple episodes of AKI may also accelerate progression to ESKD, a pointed concern given the rising incidence of AKI in a warming world. Reference Coca, Singanamala and Parikh 23 , Reference Sykes, Asar and Ritchie 24 A meta-analysis found that each 1-degree Celsius increment in ambient temperature was associated with a 1% rise in kidney morbidity assessed as acute hospital presentations.Reference Gallagher, Smyth and Jha 22 , Reference Liu, Varghese and Hansen 25
Gallagher et al.Reference Gallagher, Smyth and Jha 22 referenced the analyses of Qu and colleagues, whose team quantified the relationship between extreme ambient heat and emergency department visits for kidney diseases—primarily presenting as AKI, nephrolithiasis, and urinary tract infections.Reference Qu, Zhang and Boutelle 26 Aligned with our current focus, Remigio and colleagues examined the predictive relationship between rising ambient temperatures, and increased rates of hospital admissions, and deaths for hemodialysis patients with ESKD.Reference Remigio, Jiang and Raimann 27 , Reference Remigio, Turpin and Raimann 28 Strategies are being devised to safeguard ESKD patients from heat extremes (Table 1).
Table 1. Extreme heat: tips for dialysis patientsFootnote †
† Adapted from Kidney Community Emergency Response (KCER). Extreme Summer Heat: Tips for Dialysis Patients.
As a contributor to the increasing global kidney disease burden during this century, global warming has produced a newly recognized ailment in workers who are chronically exposed to heat in their outdoor occupational roles, variously described as heat-triggered CKD of unknown origin/uncertain etiology, tubulointerstitial CKD, or heat stress nephropathy, as well as Mesoamerican nephropathy.Reference Sorensen and Garcia-Trabanino 29 –Reference Chapman, Hess and Lucas 32 This raises concerns about the potential for prolonged heat exposure during power blackouts that may occur due to climate-triggered disasters or extended power outages.
Climate Change Worsens Hurricane Hazards for Patients With ESKD
Salient, potentially life-threatening, hurricane-associated risks for patients with ESKD include disruption of hemodialysis schedules, and healthcare services, as well as respiratory disease transmission risks during evacuation and sheltering, and exposure to heat and humidity, including long-term displacement for those who cannot return home following evacuation.
Climate change exerts a pervasive influence on the hazards of hurricanes, making these storm systems more dangerous for affected communities. 33 –Reference Knutson, Camargo and Chan 36 Atlantic hurricane activity has increased in recent decades.Reference Emanuel 37 Regarding wind hazards, hurricanes are becoming stronger, with higher average peak wind speeds, and more rapid intensification, as well as more category 4 and 5 storms.Reference Emanuel 37 –Reference Elsner, Kossin and Jagger 44 Regarding water hazards, hurricanes more often produce precipitation extremes and a towering storm surge, worsened by sea level rise.Reference Knutson, McBride and Chan 34 –Reference Knutson, Camargo and Chan 35 , Reference Risser and Wehner 45 –Reference Shultz, Kossin and Shepherd 47 The forward speed (“translational speed”) of Atlantic hurricanes tends to decrease as these rotating systems move onshore, causing them to stall, hence prolonging the duration of impact for coastal communities.Reference Hall and Kossin 48 , Reference Kossin 49 Adding to the devastation, landfalling hurricanes are remaining intact for longer durations.Reference Li and Chakraborty 50 Some hurricanes stay over water, just offshore, hugging the coastlines, and draw immense power from the warm waters, simultaneously producing flooding rains.Reference Wang and Toumi 51
Climate-Driven Hurricanes are Multi-Hazard Cluster Events
Climate change influences the severity and complexity of hurricane hazards. Scientists have advanced the perspective that changing climate and weather events represent clusters of hazards, whose impacts synergize.Reference Zscheischler, Martius and Westra 52 Analyses show that Atlantic hurricanes are typically followed several days later by heat events with high heat index readings; a dangerous combination for patients with ESKD.Reference Guido, Allen and Mason 53 With increasing frequency, multiple hurricanes are striking the same geographic area just days apart; multiple impacts increase the damage and disruption for patients and providers alike.Reference Xi, Lin and Gori 54
Compound disaster case studies are proliferating. Published examples include a tropical cyclone combined with extreme heat,Reference Matthews, Wilby and Murphy 55 and a triad of tropical cyclone, blackout, and heatwave.Reference Feng, Ouyang and Lin 56 Also notable are studies that describe single storm systems with coastal saltwater hazards, including sea level rise, storm surge, and wave action coupled with sustained heavy rains, leading to inland freshwater surface and river flooding.Reference Gori, Lin and Xi 57 –Reference Marsooli, Lin and Emanuel 59
The Context of Compounding Tropical Cyclone Risks for Patients With ESKD
While most reviews of the impact of natural hazards on patients with ESKD, and disruption of dialysis services tend to feature extreme weather events in the Americas,Reference Smith, Zucker and Frasso 4 Gray and colleagues examined natural disasters in relation to dialysis care in the Asia-Pacific.Reference Gray, Wolley and Liew 60 Regardless of geography, climate-driven Atlantic hurricanes (as well as Pacific typhoons) result in widespread power outages, abruptly exposing affected citizens; who normally rely on air conditioning for climate control, to prolonged and extreme heat.Reference Smith, Zucker and Frasso 4 , Reference Gray, Wolley and Liew 60
The post-hurricane environment is frequently stormy, hot, and humid. Most “cooling centers” like shopping malls will be affected by power outages. Storm survivors must frequently engage in clearing debris and making emergency repairs that require considerable exertion and resources. Municipal water sources and private wells depend on electricity, hence, there is a high likelihood of drinking water contamination.
The post-impact risk landscape may prove deadly for patients with ESKD. Using the United States Renal Data System (USRDS) database, Blum et al. (2022) conducted a 20-year longitudinal analysis of 187 388 patients undergoing maintenance dialysis.Reference Blum, Feng and Anderson 7 The 29 849 patients who had been exposed to an Atlantic hurricane experienced a significantly higher rate of mortality (hazard ratio: 1.13, 95% confidence interval, 1.05 - 1.22) during the first 30 days following impact compared to their non-exposed counterparts. The authors concluded that dialysis-dependent patients are especially vulnerable during hurricanes in this era of “anthropogenic climate change.”Reference Blum, Feng and Anderson 7 Johnson et al. explored the human physiological impact and adaptations in a setting of climate change and water shortage.Reference Marsooli, Lin and Emanuel 59 , Reference Gray, Wolley and Liew 60 Power outages and water shortages have crippling effects on dialysis center operations even when storm damage to these facilities is minimal.Reference Johnson, Stenvinkel and Jensen 61 , Reference Johnson, Sánchez-Lozada and Newman 62
Less than 2 decades ago, before most nephrologists were actively discussing climate change and kidney health, Hurricane Katrina devastated the Gulf Coast with severe consequences for patients with ESKD. Kopp and colleagues conducted detailed analyses of the failures of dialysis services and systems during and following Hurricane Katrina.Reference Kopp, Ball and Cohen 5 –Reference Kopp, Ball and Cohen 6 , Reference Anderson, Cohen and Kutner 63 These authors provided detailed guidance for improving the preparedness of patients living with ESKD, as well as improving the rebound capabilities of dialysis services following a climate disaster.Reference Kopp, Ball and Cohen 5 , Reference Kopp, Ball and Cohen 6 This guidance must be continuously updated as climate change effects become more pronounced (Table 2).
Table 2. Disaster preparedness strategies for patients with ESKD by disaster phase
Kleinpeter and colleagues chronicled the experiences of patients on maintenance dialysis in the context of massive disruptions to healthcare delivery during back-to-back Hurricanes Katrina and Rita in 2005, and during Hurricanes Ike and Gustav in 2008.Reference Kleinpeter 64 , Reference Kleinpeter 65 Kleinpeter’s observations, in her roles as a nephrologist, a public health practitioner, and a New Orleans resident closely connected to local communities, are particularly astute as she describes Katrina’s disproportionate impact on dialysis-dependent patients from communities targeted for marginalization.Reference Kleinpeter 64 The Katrina experience prompted nephrologists, dialysis services providers, and dialysis-dependent patients living with ESKD to engage in intensive disaster planning aimed at decreasing morbidity, and mortality during future storms. Mitigation planning paid dividends just 3 years later during the impacts of Hurricanes Gustav and Ike.Reference Kleinpeter 65 During Hurricane Gustav, most evacuated ESKD patients received uninterrupted treatment. Patients who evacuated to Baton Rouge where damage and power outages were extensive, missed a single session, but there were no reported adverse outcomes.Reference Kleinpeter 65 Nevertheless, the path forward was not steadily upward and 2011 Hurricane Sandy was declared a “kidney failure disaster.”Reference Lempert and Kopp 66 , Reference Murakami, Siktel and Lucido 67 During the ensuing decade, Barraclough et al. raised the alarm regarding the effects of climate change on renal health, including heat extremes, climate-driven weather events, and the expanding range of vector-borne diseases.Reference Barraclough, Holt and Agar 68 , Reference Barraclough, Blashki and Holt 69
In 2021, 16 years to the day following Katrina’s landfall, Hurricane Ida came ashore in New Orleans, setting off prolonged power outages, and disrupting health care services.Reference Shultz, Trapido and Kossin 70 Kleinpeter was interviewed regarding the situation with ESKD patients.Reference Phend 71 She reported that many of New Orleans’ 6000 dialysis-dependent patients had evacuated ahead of the storm and dozens of dialysis services were back online just days after impact.Reference Barraclough, Blashki and Holt 69 Patients were advised to remain where they had evacuated, due to the ongoing COVID-19 Delta surge that filled area hospitals and threatened to trigger viral outbreaks in dialysis centers. Planning and preparedness actions, aided by the availability of electronic medical records, allowed many ESKD patients to preemptively evacuate, and receive dialysis on a schedule that avoided complications requiring hospitalization. Kleinpeter asserted that Ida’s climate-driven rapid intensification to Category 4 windspeeds limited the numbers of patients who had time to evacuate to safer locations where dialysis services remained operational.Reference Phend 71
The Hurricane Ian story: A Turning Point
During the 2 decades following the debacle of Hurricane Katrina in 2005, leading kidney dialysis providers have made strides toward safeguarding their caseloads of patients with ESKD who require in-center hemodialysis. Hurricane Ian’s passage across the Florida Peninsula illustrates how effective disaster preparedness and response actions have become, despite the increasing climate-potentiated disaster risks that combine climate driven hurricane hazards with power blackouts and prolonged heat waves in the aftermath (Figure 2).
Figure 2. Hurricane Ian, prior to landfall in Southwest Florida, September 28, 2022.
Category 5 Hurricane Ian made landfall along Florida’s Gulf coast on September 28, 2022, slowing as the vast system came ashore. Ian was the fifth-strongest storm in history to strike the US mainland, setting off tornadoes, driving a massive storm surge onshore, and drenching central Florida with flooding rains. Upon re-analysis by the US National Hurricane Center, Hurricane Ian was upgraded to a Category 5 storm, the strongest rating on the Saffir-Simpson Hurricane Wind Scale.
Ian typified the tropical cyclone hazard features that increasingly characterize Atlantic storms under the influence of climate change: stronger, wetter, and stalling. Over the next day, Ian traversed the Florida peninsula diagonally.
Complex logistics are required for protecting patients with ESKD and rapidly restoring dialysis services. What measures were taken to safeguard patients and minimize treatment disruptions? Coauthors interviewed disaster managers from 2 of the largest kidney dialysis services corporations to find out. Managers described how they adapted their operations to the challenges posed by Hurricane Ian.
From the moment the tropical system was identified by the National Hurricane Center (NHC), disaster preparedness professionals at the dialysis services monitored the storm’s path and intensity forecasts, activating their disaster plans well before the system moved toward Florida’s west coast. NHC’s advanced capabilities for tracking tropical systems and predicting their likely trajectory, as well as issuing timely warnings, allowed some ESKD patients to evacuate prior to Ian’s impact, and arrange to receive treatment in locales distant from the storm’s path. Evacuation was not an option for most ESKD patients, for whom ongoing access to treatment relied on the extraordinary actions of the dialysis services providers.
Preparing Dialysis Centers and Safeguarding Staff
Hurricane Ian triggered the preemptive cancellation of hemodialysis services for thousands of ESKD patients. As Ian’s path and timetable became more precisely defined, dialysis providers identified centers that would be closed during the storm. Prior to impact, dialysis centers arranged for solid and biological wastes and “sharps” to be picked up, to reduce the risk that biological wastes might contaminate flood waters.
Anticipating widespread power outages during hurricanes, many dialysis centers are equipped with diesel-powered auxiliary generators. In other instances, generators were transported and staged nearby, outside the strike zone, and ready for delivery to any centers needing back-up power. Disasters notoriously disrupt supply chains. Therefore, dialysis providers ordered convoys of tanker trucks, filled with diesel fuel to run the generators for several days, and additional tanker trucks carrying gasoline that was reserved for filling the gas tanks of dialysis center personnel. Fortunately, increasing numbers of dialysis providers are shifting to microgrid systems to power their facilities in emergencies, but the conversion was not complete at the time of Hurricane Ian.
To ensure that staff were both safe and available, the dialysis providers reserved hotel rooms and other accommodations near the dialysis center to house both employees and their family members. Employee families were able to stay connected and secure during the storm, and in the immediate aftermath, and be together during non-work hours. Palletized food supplies were brought to the centers to feed the staff.
Kidney dialysis requires 300 - 350 liters (80 - 90 gallons) of clean water per dialysis treatment per patient. Dialysis providers pre-staged tankers of water just outside the impact zone to supply dialysis center needs when water pressure dropped during power outages or local water supplies became contaminated. Dialysis providers also deployed technical support personnel to make rapid repairs in centers that sustained minor damage, and to check and recalibrate the dialysis equipment.
Preparing Patients With ESKD
One advantage of dialysis services is that they are guaranteed to see all patients—for whom dialysis is a lifeline for survival—in the days immediately preceding impact. During Ian’s approach, dialysis providers created a case transition report for each patient and packed a personalized, sealed plastic bag with essential dialysis information, and national emergency contact numbers, and guidance about how patients would be contacted with information regarding nearby dialysis centers that had resumed operations.
Many patients had dialysis sessions moved up so they could be “pre-dialyzed” prior to storm impact. Patients received their plastic pouches along with guidance to answer their cellphones when called by dialysis services staff. During these pre-storm dialysis encounters, patient contact and locator information was updated in the companies’ disaster tracker databases, with servers located in states distant from Florida.
The whereabouts of patients who evacuated were tracked. Building upon their nationwide patient and facilities communications networks, dialysis providers were able to match patient locator information with dialysis centers’ operational status, and guide patients to the nearest open centers in their vicinity. Tracker information was updated continuously as the situation changed dynamically.
Hurricane Ian moved swiftly across the Florida peninsula. Dialysis center personnel immediately began to reach out to their caseloads of ESKD patients using their personal cellphones. Disruption of access to kidney dialysis may rapidly devolve into life-threatening complications, so dialysis providers in the US have been granted permission to use the FirstNet communication systems developed for first responders and emergency personnel, giving them precedence to access any available cellular services.
Once a staff member was able to reach an ESKD patient, they immediately inquired about the patient’s welfare and safety, and focused any renal health issues. On occasion, these initial contacts could result in a life-saving intervention. During the Ian response, 1 dialysis provider orchestrated a National Guard airborne rescue for an ESKD patient stranded on the roof of his flooded home. Most commonly, the most important information conveyed was to inform each patient about open and accessible dialysis centers in their area, and to problem-solve as needed to make sure the patient was able to get to the center.
Rapid Restoration of Dialysis Services
During the passage of Hurricane Ian, the 2 dialysis providers initially closed 232 centers in western and central Florida. Staff from these 2 dialysis services’ providers contacted and traced 100% of their storm affected ESKD patients within 72 hours. Two days after landfall, almost 50% of the dialysis centers had reopened. By day 5, 230 out of the 232 (99.1%) centers were serving their patients. Almost all patients were dialyzed within 4 days or less. Only a handful waited 5 days to resume dialysis. Moreover, even with slightly longer than usual intervals between treatments, none of the patients served at these dialysis clinics required hospitalization for a kidney emergency, and 100% of patients successfully survived their encounter with Hurricane Ian.
Area hospitals reported a surge of ESKD patients. Dialysis providers worked proactively to offload this added burden on area hospitals that were already dealing with a surge of hurricane-related emergencies and not well equipped to provide hemodialysis services by allowing these individuals (who were not from their regular caseloads) to receive dialysis at their specialized centers. In this time of crisis, most providers accepted and dialyzed any patient who presented themselves needing a treatment.
The remarkable actions taken by these large hemodialysis providers that operate internationally in multiple countries worldwide go beyond the basics as illustrated by the case study of Hurricane Ian. Not all providers have reached this level of sophistication or effectiveness. To move all providers to an optimal level of performance, in the US, all Medicare, and Medicaid-participating entities are required to follow the guidance of the Emergency Preparedness Rule issued by CMS.gov. 72 The 4 core elements for all categories of entities are to have an all-hazards risk assessment/emergency plan, policies as well as procedures, a communication plan, and regular training and testing. CMS provides specific emergency preparedness guidelines for dialysis facilities. 73
Given the pronounced risks for patients with ESKD, the pragmatic and heroic actions of these dialysis providers during Hurricane Ian were truly exemplary. A more personalized view of dialysis center operations was offered by a Hurricane Ian survivor and patient with ESKD who provided these observations on his storm experience:
“I was able to get to my dialysis clinic and receive my scheduled dialysis with no problems.”
“They gave us instructions and procedures before the hurricane that told us what not to eat and to avoid drinking too many fluids.”
“They also said to go to the nearest emergency room if we missed a dialysis session and began to feel bad.”
“They gave us each a bottle of an emergency medication that we should take in the event that we miss a dialysis session.”
“It was easy. Everything was easy.”
Hurricane Ian moved on, but the heat lingered in the aftermath. While the impact phase of Hurricane Ian’s passage through Florida lasted just 1 day, subsequent months proved challenging for ESKD patients. Although dialysis centers were operating, many patients who remained in the storm-ravaged area were exposed to dangerous heat as power took weeks to restore at the household level, and stagnant flood waters added to the humidity and stifling heat index.
Concluding Comments
Continuous innovation is critical for protecting the well-being of medically vulnerable patients in this era of compounding disasters. Storm by storm, disaster by disaster, lessons are learned that allow protocols and procedures to be improved. As exemplified by the response to Hurricane Ian, advances in the protection and care of patients with ESKD whose lives depend on access to hemodialysis, lead the way. Evolving strategies developed by kidney care providers serve as a template for other MHRP populations, including patients living with cancer.Reference Hassan, Nogueira and Lin 74
The early decades of the 21st century have witnessed accelerating climate change and ravaging pandemics, playing out above a cannonade of natural hazard events. These complex and cascading disaster risks are globally networked. Patients with ESKD face inordinate threats to health during hurricanes, wildfires, floods, and other extreme weather events that cause power outages and disrupt dialysis center operations. Grappling with the long tail of storm recovery, Hurricane Ian survivors with ESKD have been further endangered by the extreme and unrelenting heat of 2023. Disaster preparedness strategies for protecting patients with ESKD must be continuously enhanced and customized to meet their distinctive needs.
Competing interest
All authors indicate that they have no disclosures or conflicts of interest to declare.
