renal care for displaced patients in host countries...• turkey started accept syrian refugees...
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Rümeyza Kazancıoğlu, MD
Bezmialem Vakif University
School of Medicine, Division of Nephrology
Istanbul TURKEY
RENAL CARE FOR DISPLACED
PATIENTS IN HOST COUNTRIES
• Definitions
• Current Status
• ISN Report
• Data from Turkey
• Data from BVU
REFUGEES WORLWIDE
SYRIAN REFUGEES
IMMIGRANTS ????
A REFUGEE IS …
A person who "owing to a well-founded fear of being
persecuted for reasons of race, religion,
nationality, membership of a particular social
group, or political opinion, is outside the country
of his nationality, and is unable to or, owing to such fear,
is unwilling to avail himself of the protection of that
country"
Turkey’s asylum policy
characterized by
‘geographical limitations’
Hence Syrians’ are recognized
as guests
Improved capabilities in the
years to follow
Local hosting or working with
refugee integration without
assimilation
A GUEST IS …
Samari G. The response to Syrian refugee women’s health needs in Lebanon, Turkey and
Jordan and recommendations for improved parctice ‘Knowledgeand Action’ Humanity in
Action 2015. Humanity in Action Inc.
• The United Nations has declared the Syrian crisis the
worst humanitarian crisis of the 21st century
• Since March 2011
• Becoming a public health disaster
Samari G. The response to Syrian refugee women’s health needs in Lebanon, Turkey and
Jordan and recommendations for improved parctice ‘Knowledgeand Action’ Humanity in
Action 2015. Humanity in Action Inc.
“RENAL DISASTER”
Kidney Int 1993; 44: 479-83
Br Med J 1989; 298: 443-5
DISASTER NEPHROLOGY
The difference in the response required for a
conflict that becomes protacted over a period
of years versus the response required for a
sudden onset disaster
Sever MS, Lameire N, Van Biesen W, Vanholder R.. Disaster nephrology: a new
concept for an old problem. Clin Kidney J. 2015 Jun;8(3):300-9.
DISASTER NEPHROLOGY
• Both require humanitarian intervention to provide
lifesaving care in the short term
• A protracted confict requires a more
sustained effort by the international
community
Klosson M. http://ww.mei.edu./content/at/caring-most-vulnerable-populations-affected-conflict-
middleeast…..
DIALYSIS DURING CRISIS
• During disasters and war situations, the
delivery of health care services including HD
can be interrupted
– destruction of medical facilities
– destruction of infrastructure
– lack of healthcare personnel
– shortage of equipment and supplies
– interruption of water
Al-Makki A, Rifai AQ, Murad L, et al The Syrian national kidney foundation: Response for the
need of kidney patients during the crisis. Avicenna J Med 4(3): 54-57 (2014)
• The conduction of HD can also be interrupted by
technical or electrical issues such as electrical
blackouts
• Syrian Conflict
– All or some components of renal care were
inadequate or completely absent due to security
reasons, unavailability of supplies, interruption of
water and electricity, absence of maintenance and
support and absence of equipment and essential
materials
Al-Makki A, Rifai AQ, Murad L, et al The Syrian national kidney foundation: Response for the
need of kidney patients during the crisis. Avicenna J Med 4(3): 54-57 (2014)
DIALYSIS DURING CRISIS
• Steps
– Funding for replacing broken health
systems
– Rebuilding infrastructure
– Strengthening the national capacity
Klosson M. http://ww.mei.edu./content/at/caring-most-vulnerable-populations-affected-conflict-
middleeast…..
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
AIM
• The Renal Disaster Relief Task Force (RDRTF) of the
International Society of Nephrology (ISN), the
European Renal Association/European Dialysis and
Transplant Association (ERA-EDTA), and Médecins
Sans Frontières (MSF) surveyed the nephrological
community on practical aspects of renal
replacement therapy and nephrological care for
refugees with ESKD
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
AIM
The objective was to gather information on the size of
the problem and on the views of the nephrological
community on this topic
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
METHODOLOGY
• A web-based tool (SurveyMonkey) to invite all ISN
members in broader Europe and the Middle East to
participate in an anonymous survey
• Survey focussed on individual experiences of
individual centres and nephrologists in the
preceding 4 months
• Internet protocol addresses were monitored to
ensure that each centre contributed only once
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
METHODOLOGY
• The management of refugees with ESKD using
closed questions for quantitative and descriptive
data
• Qualitative opinions using a 5-point Likert scale.
• Responses were automatically retrieved into an
Excel spreadsheet
• Statistical analysis using SPSS, version 22 (IBM) and
results as percentages or absolute numbers
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
SURVEY Questions on demography of the centre
• Country, region
• No of regular chronic HD patients at the centre
• No of refugee patients treated with chronic dialysis in
your centre over the last 4 months
• No of chronic dialysis sessions provided to refugee
patients in your centre over the last 4 months
• No of acute dialysis sessions provided to refugee
patients in your centre over the last 4 months
• No of refugee patients with acute of chronic need for
dialysis declined access to dialysis in your centre over
the last 4 months
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
SURVEY
Questions on reimbursement/financing of dialysis
treatment of refugee patients
Concerning the legal rights of refugee patients for
dialysis
Questions on attitude towards transplantation of
refugee dialysis patients
Questions on attitude towards refugee patients
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
SURVEY • Indicate on a scale from 1 (totally disagree) to 5
(strongly agree) your opinion on the following
statements
– We have the moral duty to take care of refugee patients
who need dialysis
– We had open discussions in our team on the ethical
aspects of accepting refugees on dialysis
– I feel comfortable in offering refugee patients dialysis
treatment
– I can feel that the management of refugee patients
creates extra tension and stress in the team
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
• 298 centres provided complete responses
• Dialysed 631 refugees in the 4 months before the
survey
• Total population of the centres who underwent
regular dialysis was 40378
• Refugees represented about 1.5% of the represented
dialysis population
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
22%
15%
9%
5%
0%
9%
40%
Central and Eastern Europe
Southern Europe
Middle East
North Africa
North America
Scandinavian Europe
Western Europe
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
177
76
23
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
>1 refugees were refused dialysis by 33 centres
1 centre very close to an active war zone reported to
refuse 250 patients in need of dialysis because of no
resources
1 centre in Western Europe declined 25 refugee
patients (but accepted 25 others) as the cost was to
be supported by the nephrology department
Other centres reporting high refusal rates stated that
they had requested patients to pay for their
treatment
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
• 24.5% centres received clear instructions from their
government that refugees who needed dialysis
should receive it
• 46% centres did not receive instructions from their
government, but did obtain approval from their
hospital administration to dialyse refugee patients if
needed
• Only one centre stated that they received orders
from the government not to treat refugee patients
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
3.7% of centres, this order not to treat was issued by
the hospital administration
25% of centres (74) reported that they were not
aware of any instruction from their government or
from the hospital administration
60 centres 0 patient
8 centres 1 patient
2 centres 2 patients
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
W Van Biesen et al.: Dialysis for refugee patients Kidney International Supplements (2016) 6,
35–41; http://dx.doi.org/10.1016/ j.kisu.2016.09.001
RESULTS
Disaster and Emergency Management Authority (AFAD)
The number of registrated Syrian
‘refugees’ in Turkey
TURKISH EXPERIENCE
• Turkey started accept Syrian refugees since March
2011
• As of September 2016, Disaster and Emergency
Management Authority (AFAD) of Turkey operates 26
refugee camps (named as “Temporary Sheltering
Centers” by the Turkish authorities) hosting 285
thousand Syrian refugees in addition to 2.5 million
Syrian refugees living in various cities in out-camp
settlements
• The expenses of the Turkish government for the
SRTPs have now exceeded 10 billion dollars (May 11,
2016 estimates) according to the UN standards
Health Status Survey of Syrian Refugees* in Turkey Non-communicable Disease Risk Factors Surveillance
among Syrian Refugees Living in Turkey Oct 2016 Prepared by Prof. Dr. Mehmet BALCILAR
AFAD, Ankara, Turkey;
TURKISH EXPERIENCE
DIALYSIS FACILITIES IN TURKEY
345 Syrian prevalent HD patients
Unpublished data with the courtesy of Turkish MoH
DIALYSIS FACILITIES IN TURKEY
345 Syrian prevalent HD patients
Unpublished data with the courtesy of Turkish MoH
Dialysis Centers
n %
Ministery of Health Dx Centers 232 67.2
University Dx Centers 8 2.3
Private Dx Centers 105 30.4
HEMODIALYSIS IN TURKEY
Unpublished data with the courtesy of Turkish MoH
Age and Gender of the patients at the end of 2016
Age Male Female Total
n n n
0-19 7 10 17
20-44 64 50 114
45-64 76 65 141
65-74 18 26 44
≥75 13 13 26
Total 178 167 345
HEMODIALYSIS IN TURKEY
Unpublished data with the courtesy of Turkish MoH
HEMODIALYSIS IN TURKEY
Unpublished data with the courtesy of Turkish MoH
Dialysis duration in Turkey
N %
<1 month 29 8.4
1-3 months 72 20.8
4-6 months 53 15.3
7-12 months 119 34.4
13-24 months 36 10.4
>24 months 36 10.4
Total 345 100
HEMODIALYSIS IN TURKEY
Unpublished data with the courtesy of Turkish MoH
HEMODIALYSIS IN TURKEY
Unpublished data with the courtesy of Turkish MoH
HEMODIALYSIS IN TURKEY
Unpublished data with the courtesy of Turkish MoH
Hepatitis and HIV serologies
n
HBsAg (+) 7
Anti-HCV (+) 23
HBsAg (+), Anti-HCV (+) 0
HIV (+) 0
Total 30
COMPARISON OF SOCIO-ECONOMIC
SITUATION
OF TURKISH AND SYRIAN HEMODIALYSIS
PATIENTS
N. AYDIN¹, C. DOĞAN¹, F. TURAN¹, E. YILMAZ¹, Y. VARDAR², E.BALCI²,
M. YILMAZ¹, A. KUDU¹, S. YUCEL¹, S. APAYDIN¹
¹Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, TURKEY
²Bagcilar Training and Research Hospital, Istanbul, TURKEY
Presented at 45th EDTNA/ERCA International Conference
September 17–20, 2016 Valencia, Spain
• 23 Syrian HD patients
• 82 socially underprivileged
Turkish HD patients
PATIENTS AND METHODS
Presented at 45th EDTNA/ERCA International Conference
September 17–20, 2016 Valencia, Spain
• 23 (12 female, 11 male) Syrians patients
• 82 (41 female, 41 male) Turkish patients
• Median age was 50.52±18.96 (range 17-92) years
RESULTS
Presented at 45th EDTNA/ERCA International Conference
September 17–20, 2016 Valencia, Spain
Syrian patients were younger (p<0.001)
34,1
55,13
0
10
20
30
40
50
60
Syrians Turkish
Mean age
RESULTS
Presented at 45th EDTNA/ERCA International Conference
September 17–20, 2016 Valencia, Spain
Temporary HD catheters were more frequent in Syrian
than Turkish patients (p=0.012)
34,8
65,2
9,8
90,2
0
10
20
30
40
50
60
70
80
90
100
Temporary catheter AV Fistula and graft
Syrian patients
%
Presented at 45th EDTNA/ERCA International Conference
September 17–20, 2016 Valencia, Spain
RESULTS
Evaluated 130 children
(between the age
of 1 month to 17 years)
admitted to the hospital
from September 2012 to
January 2015, retrospectively
Eighteen children with ESRD were on peritoneal
dialysis (7 patients) or hemodialysis (11 patients).
The preference of hemodialysis was common,
probably because of unsuitable living conditions.
Unfortunately, only 8 patients were being visited
regularly in spite of all free medical supports. We
observed that a few parents accepted the disease
as a fate and refused the treatment options.
DIALYSIS FACILITIES IN TURKEY
BEZMIALEM
01.12.2015 - 17.04.2017
DOCTORS WORLDWIDE AT BEZMIALEM OUTPATIENT CLINIC
CLINIC OUTPATIENT CLINIC NUMBER OF PATIENTS
Family Medicine 16.037 7.351
Internal Medicine 15.832 6.533
Pediatrics 15.504 7.733
General Surgery 11.932 7.668
Psychiatry 437 259
Gyn and Obs 10.015 6.014
TOTAL 65535 35.558
03.12.2013 - 17.04.2017
HEMODIALYSIS AT BEZMIALEM
BEZMIALEM
PATIENTS AGE SEX
NO OF
SESSIONS
AKI/CK
D AVF/CATHETER HEPATITIS OUTCOME
K M 67 M 9
FIRST
DX CATHETER NEGATIVE CKD?
T A 70 F 3
FIRST
DX CATHETER NEGATIVE CKD?
H H 55 F 5
FIRST
DX CATHETER NEGATIVE CKD?
M A 45 F 1 CKD AVF NEGATIVE CKD?
A Ş 61 F 5
FIRST
DX CATHETER NEGATIVE RECOVERED
M A 43 M 406 CKD AVF NEGATIVE STILL WITH US ON HD
F H 11 M 65 CKD
CATHETER
/AVF NEGATIVE RENAL TX
N O 64 F 8 CKD CATHETER HCV +
MOVED TO A NEW CITY STILL
ON HD
CONCLUSION
• The ever-shifting nature of international politics
means that the nephrological community must
anticipate global crises
• Refugee crises larger than the current one are likely
to occur because of the growing world population,
political frictions, and the increasing impact of
disasters, especially on destitute populations
CONCLUSION
• Such crises pose ethical and health care related
problems.
• Our international nephrological community must
now decide how it can provide care for patients with
kidney disease in conditions currently unfamiliar to
us.
THANK YOU FOR YOUR INTEREST
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