Renal care for displaced patients in host countries...• Turkey started accept Syrian refugees since March 2011 • As of September 2016, Disaster and Emergency Management Authority

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

http://dx.doi.org/10.1016/




AIM

The objective was to gather information on the size of

the problem and on the views of the nephrological

community on this topic





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





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





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





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





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









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





RESULTS

22%

15%

9%

5%

0%

9%

40%

Central and Eastern Europe

Southern Europe

Middle East

North Africa

North America

Scandinavian Europe

Western Europe





RESULTS

177

76

23





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





RESULTS





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





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





RESULTS





RESULTS





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


345 Syrian prevalent HD patients


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


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





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







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



• 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



Syrian patients were younger (p<0.001)

34,1

55,13

0

10

20

30

40

50

60

Syrians Turkish

Mean age

RESULTS



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

%



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.


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


H H 55 F 5

FIRST


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

Documents

Renal care for displaced patients in host countries...• Turkey started accept Syrian refugees since March 2011 • As of September 2016, Disaster and Emergency Management Authority