Disasters, children and the kidneys


Following disasters, children are physically, psychologically and socially more vulnerable than adults; consequently, their morbidity and mortality are higher. The risks are especially high for orphans and unaccompanied children who are separated from their families, making them frequently victims of human trafficking, slavery, drug addiction, crime or sexual exploitation. Education of children and families about disaster-related risks and providing special protection in disaster preparedness plans may mitigate these threats. Kidney disease patients, both paediatric and adult, are extra vulnerable during disasters, because their treatment is dependent on technology and functioning infrastructure. Acute kidney injury, chronic kidney disease patients not on dialysis and dialysis and transplant patients are faced with extensive problems. Overall, similar treatment principles apply both for adults and paediatric kidney patients, but management of children is more problematic, because of substantial medical and logistic difficulties. To minimize drawbacks, it is vital to be prepared for renal disasters. Preparedness plans should address not only medical professionals, but also patients and their families. If problems cannot be coped with locally, calling for national and/or international help is mandatory. This paper describes the spectrum of disaster-related problems in children and the specific features in treating acute and chronic kidney disease in disasters.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    World Health Organization (WHO). Glossary of Humanitarian Terms. https://www.who.int/hac/about/reliefweb-aug2008.pdf. Accessed 06 May 2019

  2. 2.

    Hagopian A, Flaxman AD, Takaro TK, Esa Al Shatari SA, Rajaratnam J, Becker S, Levin-Rector A, Galway L, Hadi Al-Yasseri BJ, Weiss WM, Murray CJ, Burnham G (2013) Mortality in Iraq associated with the 2003-2011 war and occupation: findings from a national cluster sample survey by the university collaborative Iraq mortality study. PLoS Med 10:e1001533

    PubMed  PubMed Central  Google Scholar 

  3. 3.

    United Nations Children’s Fund (UNICEF). Children and disasters: Building resilience through education. https://www.unisdr.org/we/inform/publications/24583. Accessed 06 May 2019

  4. 4.

    Grindlay J, Breeze KM (2016) Planning for disasters involving children in Australia: a practical guide. J Paediatr Child Health 52:204–212

    PubMed  Google Scholar 

  5. 5.

    United Nations Children’s Fund (UNICEF). Children on the move, Key facts & figures. https://data.unicef.org/wp-content/uploads/2018/02/Data-brief-children-on-the-move-key-facts-and-figures-1.pdf. Accessed 06 May 2019

  6. 6.

    Guha-Sapir D, Schluter B, Rodriguez-Llanes JM, Lillywhite L, Hicks MH (2018) Patterns of civilian and child deaths due to war-related violence in Syria: a comparative analysis from the violation documentation center dataset, 2011-16. Lancet Glob Health 6:e103–e110

    PubMed  Google Scholar 

  7. 7.

    Spinella PC, Borgman MA, Azarow KS (2008) Pediatric trauma in an austere combat environment. Crit Care Med 36:S293–S296

    PubMed  Google Scholar 

  8. 8.

    Lozon MM, Bradin S (2018) Pediatric disaster preparedness. Pediatr Clin N Am 65:1205–1220

    Google Scholar 

  9. 9.

    Er E, Corbacioglu SK, Guler S, Aslan S, Seviner M, Aksel G, Bekgoz B (2017) Analyses of demographical and injury characteristics of adult and pediatric patients injured in Syrian civil war. Am J Emerg Med 35:82–86

    PubMed  Google Scholar 

  10. 10.

    Celikel A, Karbeyaz K, Kararslan B, Arslan MM, Zeren C (2015) Childhood casualties during civil war: Syrian experience. J Forensic Legal Med 34:1–4

    Google Scholar 

  11. 11.

    Sarisozen B, Durak K (2003) Extremity injuries in children resulting from the 1999 Marmara earthquake: an epidemiologic study. J Pediatr Orthop B 12:288–291

    PubMed  Google Scholar 

  12. 12.

    Delbiso TD, Rodriguez-Llanes JM, Donneau AF, Speybroeck N, Guha-Sapir D (2017) Drought, conflict and children's undernutrition in Ethiopia 2000-2013: a meta-analysis. Bull World Health Organ 95:94–102

    PubMed  PubMed Central  Google Scholar 

  13. 13.

    Edwards MJ, Lustik M, Eichelberger MR, Elster E, Azarow K, Coppola C (2012) Blast injury in children: an analysis from Afghanistan and Iraq, 2002-2010. J Trauma Acute Care Surg 73:1278–1283

    PubMed  Google Scholar 

  14. 14.

    Beltran Guzman I, Gil Cuesta J, Trelles M, Jaweed O, Cherestal S, van Loenhout JAF, Guha-Sapir D (2019) Delays in arrival and treatment in emergency departments: women, children and non-trauma consultations the most at risk in humanitarian settings. PLoS One 14:e0213362

    CAS  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Harville E, Xiong X, Buekens P (2010) Disasters and perinatal health:a systematic review. Obstet Gynecol Surv 65:713–728

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Richards NT, Tattersall J, McCann M, Samson A, Mathias T, Johnson A (1989) Dialysis for acute renal failure due to crush injuries after the Armenian earthquake. BMJ 298:443–445

    CAS  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Mallett LHP, Etzel Ra Md P (2018) Flooding: what is the impact on pregnancy and child health? Disasters 42:432–458

    Google Scholar 

  18. 18.

    Saulnier DD, Brolin K (2015) A systematic review of the health effects of prenatal exposure to disaster. Int J Public Health 60:781–787

    PubMed  Google Scholar 

  19. 19.

    Weissman A, Siegler E, Neiger R, Jakobi P, Zimmer EZ (1989) The influence of increased seismic activity on pregnancy outcome. Eur J Obstet Gynecol Reprod Biol 31:233–236

    CAS  PubMed  Google Scholar 

  20. 20.

    Armenian HK, Melkonian AK, Hovanesian AP (1998) Long term mortality and morbidity related to degree of damage following the 1998 earthquake in Armenia. Am J Epidemiol 148:1077–1084

    CAS  PubMed  Google Scholar 

  21. 21.

    Kar N (2009) Psychological impact of disasters on children: review of assessment and interventions. World J Pediatr 5:5–11

    PubMed  Google Scholar 

  22. 22.

    Slone M, Mann S (2016) Effects of war, terrorism and armed conflict on young children: a systematic review. Child Psychiatry Hum Dev 47:950–965

    PubMed  Google Scholar 

  23. 23.

    Becker BM Children and Disaster. In: Ciottone G, Anderson P, Der Heide EA, Jacoby I, Noji E, Suner S (eds) Disaster Medicine. Mosby, Philadelphia, pp 51–58

  24. 24.

    United Nations Children’s Fund (UNICEF) A Child is a Child. https://www.unicef.org/publications/files/UNICEF_A_child_is_a_child_May_2017_EN.pdf. Accessed 06 May 2019

  25. 25.

    International Committee of the Red Cross. Inter-agency Guiding Principles on unaccompanied and separated children. http://www.unhcr.org/refworld/docid/4113abc14.html. Accessed 06 May 2019

  26. 26.

    Bhutta ZA, Keenan WJ, Bennett S (2016) Children of war: urgent action is needed to save a generation. Lancet 388:1275–1276

    PubMed  Google Scholar 

  27. 27.

    Seaman J, Maguire S (2005) ABC of conflict and disaster The special needs of children and women. BMJ 331:34–36

    PubMed  PubMed Central  Google Scholar 

  28. 28.

    Center For Disease Control (CDC). Emergency Preparedness and Response. Natural Disasters and Severe Weather. https://www.cdc.gov/disasters/earthquakes/index.html. Accessed 06 May 2019

  29. 29.

    Vanholder R, Sever MS, Erek E, Lameire N (2000) Acute renal failure related to the crush syndrome: towards an era of seismo-nephrology? Nephrol Dial Transplant 15:1517–1521

    CAS  PubMed  Google Scholar 

  30. 30.

    Sever MS, Lameire N, Van Biesen W, Vanholder R (2015) Disaster nephrology: a new concept for an old problem. Clin Kidney J 8:300–309

    CAS  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Gibney RT, Sever MS, Vanholder RC (2014) Disaster nephrology: crush injury and beyond. Kidney Int 85:1049–1057

    PubMed  Google Scholar 

  32. 32.

    Bywaters EG, Beall D (1941) Crush injuries with impairment of renal function. Br Med J 1:427–432

    CAS  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Collins AJ (1989) Kidney dialysis treatment for victims of the Armenian earthquake. N Engl J Med 320:1291–1292

    CAS  PubMed  Google Scholar 

  34. 34.

    Solez K, Bihari D, Collins AJ, Eknoyan G, Eliahou H, Fedorov VD, Kjellstrand C, Lameire N, Letteri J, Nissenson AR, Noji EK, Wauters JP, Yamamoto Y (1993) International dialysis aid in earthquakes and other disasters. Kidney Int 44:479–483

    CAS  PubMed  Google Scholar 

  35. 35.

    Gunal AI, Celiker H, Dogukan A, Ozalp G, Kirciman E, Simsekli H, Gunay I, Demircin M, Belhan O, Yildirim MA, Sever MS (2004) Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes. J Am Soc Nephrol 15:1862–1867

    PubMed  Google Scholar 

  36. 36.

    Sever MS, Erek E, Vanholder R, Ozener C, Yavuz M, Kayacan SM, Ergin H, Apaydin S, Cobanoglu M, Donmez O, Erdem Y, Lameire N (2002) Lessons learned from the Marmara disaster: time period under the rubble. Crit Care Med 30:2443–2449

    PubMed  Google Scholar 

  37. 37.

    Sever MS, Vanholder R, RDRTF of ISN Work Group on Recommendations for the Management of Crush Victims in Mass Disasters (2012) Recommendation for the management of crush victims in mass disasters. Nephrol Dial Transplant 27(Suppl 1):i1–i67

  38. 38.

    Sheng ZY (1987) Medical support in the Tangshan earthquake: a review of the management of mass casualties and certain major injuries. J Trauma 27:1130–1135

    CAS  PubMed  Google Scholar 

  39. 39.

    Sever MS, Erek E, Vanholder R, Akoglu E, Yavuz M, Ergin H, Tekce M, Korular D, Tulbek MY, Keven K, van Vlem B, Lameire N, Marmara Earthquake Study Group (2001) The Marmara earthquake: epidemiological analysis of the victims with nephrological problems. Kidney Int 60:1114–1123

    CAS  PubMed  Google Scholar 

  40. 40.

    Vanholder R, Sever MS, Erek E, Lameire N (2000) Rhabdomyolysis. J Am Soc Nephrol 11:1553–1561

    CAS  PubMed  Google Scholar 

  41. 41.

    Sever MS, Erek E, Vanholder R, Akoglu E, Yavuz M, Ergin H, Turkmen F, Korular D, Yenicesu M, Erbilgin D, Hoeben H, Lameire N (2002) Clinical findings in the renal victims of a catastrophic disaster: the Marmara earthquake. Nephrol Dial Transplant 17:1942–1949

    CAS  PubMed  Google Scholar 

  42. 42.

    Sever MS, Erek E, Vanholder R, Kantarci G, Yavuz M, Turkmen A, Ergin H, Tulbek MY, Duranay M, Manga G, Sevinir S, Lameire N, Marmara Earthquake Study Group (2003) Serum potassium in the crush syndrome victims of the Marmara disaster. Clin Nephrol 59:326–333

    CAS  PubMed  Google Scholar 

  43. 43.

    Vanholder R, Gibney N, Luyckx VA, Sever MS, Renal Disaster Relief Task Force (2010) Renal disaster relief task force in Haiti earthquake. Lancet 375:1162–1163

    PubMed  Google Scholar 

  44. 44.

    Sever MS, Erek E, Vanholder R, Koc M, Yavuz M, Ergin H, Kazancioglu R, Serdengecti K, Okumus G, Ozdemir N, Schindler R, Lameire N, Marmara Earthquake Study Group (2002) Treatment modalities and outcome of the renal victims of the Marmara earthquake. Nephron 92:64–71

    CAS  PubMed  Google Scholar 

  45. 45.

    Oda J, Tanaka H, Yoshioka T, Iwai A, Yamamura H, Ishikawa K, Matsuoka T, Kuwagata Y, Hiraide A, Shimazu T, Sugimoto H (1997) Analysis of 372 patients with crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma 42:470–475 discussion 475-476

    CAS  PubMed  Google Scholar 

  46. 46.

    Better OS, Stein JH (1990) Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 322:825–829

    CAS  PubMed  Google Scholar 

  47. 47.

    Brown CV, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC (2004) Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? J Trauma 56:1191–1196

    PubMed  Google Scholar 

  48. 48.

    Perel P, Roberts I (2007) Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev (4):CD000567

  49. 49.

    KDIGO Acute Kidney Injury Work Group (2012) KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl 2:1–138

    Google Scholar 

  50. 50.

    United States Renal Data System 2018 USRDS annual data report: Epidemiology of kidney disease in the United States. https://www.usrds.org/2018/download/v2_c01_IncPrev_18_usrds.pdf. Accessed 06 May 2019

  51. 51.

    Kramer HJ, Townsend RR, Griffin K, Flynn JT, Weiner DE, Rocco MV, Choi MJ, Weir MR, Chang TI, Agarwal R, Beddhu S (2019) KDOQI US commentary on the 2017 ACC/AHA hypertension guideline. Am J Kidney Dis 73:437–458

    PubMed  PubMed Central  Google Scholar 

  52. 52.

    Sengul A, Ozer E, Salman S, Salman F, Saglam Z, Sargin M, Hatun S, Satman I, Yilmaz T (2004) Lessons learnt from influences of the Marmara earthquake on glycemic control and quality of life in people with type 1 diabetes. Endocr J 51:407–414

    PubMed  Google Scholar 

  53. 53.

    Saito K, Kim JI, Maekawa K, Ikeda Y, Yokoyama M (1997) The great Hanshin-Awaji earthquake aggravates blood pressure control in treated hypertensive patients. Am J Hypertens 10:217–221

    CAS  PubMed  Google Scholar 

  54. 54.

    Tomio J, Sato H (2014) Emergency and disaster preparedness for chronically ill patients: a review of recommendations. Open Access Emerg Med 6:69–79

    PubMed  PubMed Central  Google Scholar 

  55. 55.

    Sever MS, Vanholder R, Lameire N (2006) Management of crush-related injuries after disasters. N Engl J Med 354:1052–1063

    CAS  PubMed  Google Scholar 

  56. 56.

    Vanholder R, Sever MS, De SM, Erek E, Lameire N (2001) Intervention of the renal disaster relief task force in the 1999 Marmara, Turkey earthquake. Kidney Int 59:783–791

    CAS  PubMed  Google Scholar 

  57. 57.

    Ukai T (1997) The great Hanshin-Awaji earthquake and the problems with emergency medical care. Ren Fail 19:633–645

    CAS  PubMed  Google Scholar 

  58. 58.

    Sever MS, Erek E, Vanholder R, Kalkan A, Guney N, Usta N, Yilmaz C, Kutanis C, Turgut R, Lameire N (2004) Features of chronic hemodialysis practice after the Marmara earthquake. J Am Soc Nephrol 15:1071–1076

    PubMed  Google Scholar 

  59. 59.

    Kutner NG, Muntner P, Huang Y, Zhang R, Cohen AJ, Anderson AH, Eggers PW (2009) Effect of hurricane Katrina on the mortality of dialysis patients. Kidney Int 76:760–766

    PubMed  Google Scholar 

  60. 60.

    Anderson AH, Cohen AJ, Kutner NG, Kopp JB, Kimmel PL, Muntner P (2009) Missed dialysis sessions and hospitalization in hemodialysis patients after hurricane Katrina. Kidney Int 75:1202–1208

    PubMed  Google Scholar 

  61. 61.

    Shultz JM, Galea S (2017) Preparing for the next Harvey, Irma, or Maria - addressing research gaps. N Engl J Med 377:1804–1806

    PubMed  Google Scholar 

  62. 62.

    International Committee of the Red Cross (ICRC) Hidden cost of war: In Yemen, thousands could die of kidney failure. https://www.icrc.org/en/document/yemen-hidden-cost-war-thousands-kidney-dialysis-patients-risk-death. Accessed 06 May 2019

  63. 63.

    World Health Organisation (WHO) Dialysis patients in Yemen struggle to obtain regular sessions amid war. http://www.emro.who.int/countries/yem/index.html. Accessed 06 May 2019

  64. 64.

    Sakai R (1997) The Japanese experience during the Kobe earthquake: management of continuous ambulatory peritoneal dialysis patients in a disaster. Ren Fail 19:693–699

    CAS  PubMed  Google Scholar 

  65. 65.

    Ozener C, Ozdemir D, Bihorac A (2000) The impact of the earthquake in northwestern Turkey on the continuous ambulatory peritoneal dialysis patients who were living in the earthquake zone. Adv Perit Dial 16:182–185

    CAS  PubMed  Google Scholar 

  66. 66.

    National Kidney Foundation Planning for Emergencies - A Guide for People with Kidney Disease. https://www.kidney.org/atoz/content/disasterbrochurefacilities. Accessed 06 May 2019

  67. 67.

    Kleinpeter MA (2007) End-stage renal disease use in hurricane-prone areas: should nephrologists increase the utilization of peritoneal dialysis? Adv Chronic Kidney Dis 14:100–104

    PubMed  Google Scholar 

  68. 68.

    Shimmura H, Kawaguchi H, Tokiwa M, Tanabe K (2014) Impact of the great eastern Japan earthquake on transplant renal function in Iwaki city, Fukushima. Transplant Proc 46:613–615

    CAS  PubMed  Google Scholar 

  69. 69.

    Kadowaki M, Saito M, Amada N, Haga I, Nakamura A, Tokodai K (2014) Medication compliance in renal transplant patients during the great East Japan earthquake. Transplant Proc 46:610–612

    CAS  PubMed  Google Scholar 

  70. 70.

    Sharief S, Freitas D, Adey D, Wiley J (2018) Disaster preparation in kidney transplant recipients: a questionnaire-based cohort study from a large United States transplant center. Clin Nephrol 89:241–248

    PubMed  Google Scholar 

  71. 71.

    Glass RI, Urrutia JJ, Sibony S, Smith H, Garcia B, Rizzo L (1977) Earthquake injuries related to housing in a guatemalan village. Science 197:638–643

    CAS  PubMed  Google Scholar 

  72. 72.

    Donmez O, Meral A, Yavuz M, Durmaz O (2001) Crush syndrome of children in the Marmara earthquake, Turkey. Pediatr Int 43:678–682

    CAS  PubMed  Google Scholar 

  73. 73.

    Iskit SH, Alpay H, Tugtepe H, Ozdemir C, Ayyildiz SH, Ozel K, Bayramicli M, Tetik C, Dagli TE (2001) Analysis of 33 pediatric trauma victims in the 1999 Marmara, Turkey earthquake. J Pediatr Surg 36:368–372

    CAS  PubMed  Google Scholar 

  74. 74.

    Hatamizadeh P, Najafi I, Vanholder R, Rashid-Farokhi F, Sanadgol H, Seyrafian S, Mooraki A, Atabak S, Samimagham H, Pourfarziani V, Broumand B, Van Biesen W, Lameire N (2006) Epidemiologic aspects of the bam earthquake in Iran: the nephrologic perspective. Am J Kidney Dis 47:428–438

    PubMed  Google Scholar 

  75. 75.

    Zhang L, Zhao M, Fu W, Gao X, Shen J, Zhang Z, Xian M, Jiao Y, Jiang J, Wang J, Gao G, Tang B, Chen L, Li W, Zhou C, Deng S, Gu J, Zhang D, Zheng Y, Chen X (2014) Epidemiological analysis of trauma patients following the Lushan earthquake. PLoS One 9:e97416

    PubMed  PubMed Central  Google Scholar 

  76. 76.

    Sanadgol H, Najafi I, Rajabi Vahid M, Hosseini M, Ghafari A (2009) Fluid therapy in pediatric victims of the 2003 bam, Iran earthquake. Prehosp Disaster Med 24:448–452

    CAS  PubMed  Google Scholar 

  77. 77.

    Sever MS, Vanholder R (2013) Management of crush victims in mass disasters: highlights from recently published recommendations. Clin J Am Soc Nephrol 8:328–335

    PubMed  Google Scholar 

  78. 78.

    Kumar V, Ramachandran R, Rathi M, Kohli HS, Sakhuja V, Jha V (2013) Peritoneal dialysis: the great savior during disasters. Perit Dial Int 33:327–329

    PubMed  PubMed Central  Google Scholar 

  79. 79.

    Sever MS, Erek E, Vanholder R, Koc M, Yavuz M, Aysuna N, Ergin H, Ataman R, Yenicesu M, Canbakan B, Demircan C, Lameire N (2004) Lessons learned from the catastrophic Marmara earthquake: factors influencing the final outcome of renal victims. Clin Nephrol 61:413–421

    CAS  PubMed  Google Scholar 

  80. 80.

    Tanida N (1996) What happened to elderly people in the great Hanshin earthquake. BMJ 313:1133–1135

    CAS  PubMed  PubMed Central  Google Scholar 

  81. 81.

    Akbalik Kara M, Demircioglu Kilic B, Col N, Ozcelik AA, Buyukcelik M, Balat A (2017) Kidney disease profile of Syrian refugee children. Iran J Kidney Dis 11:109–114

    PubMed  Google Scholar 

  82. 82.

    Giri BR, Chapagain RH, Sharma S, Shrestha S, Ghimire S, Shankar PR (2018) Effect of the 2015 earthquake on pediatric inpatient pattern at a tertiary care hospital in Nepal. BMC Pediatr 18:28

    PubMed  PubMed Central  Google Scholar 

  83. 83.

    Otoukesh S, Mojtahedzadeh M, Cooper CJ, Tolouian R, Said S, Ortega L, Didia SC, Behazin A, Sherzai D, Blandon P (2014) Lessons from the profile of kidney diseases among afghan refugees. Med Sci Monit 20:1621–1627

    PubMed  PubMed Central  Google Scholar 

  84. 84.

    Sever MS, Lameire N, Vanholder R (2009) Renal disaster relief: from theory to practice. Nephrol Dial Transplant 24:1730–1735

    PubMed  Google Scholar 

Download references


M.S.S. is a member of and volunteer for Médecins Sans Frontières (MSF) and served as field doctor and disaster relief coordinator in many mass disasters.

L.S. treated many paediatric crush victims and contributed to paediatric relief operations after the Marmara earthquake.

R.V. coordinated and took part in several disaster relief operations in collaboration with MSF. Between 2005 and 2014, he coordinated the Renal Disaster Relief Task Force (RDRTF) of the ISN.

Author information



Corresponding author

Correspondence to Mehmet Sukru Sever.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sever, M.S., Sever, L. & Vanholder, R. Disasters, children and the kidneys. Pediatr Nephrol 35, 1381–1393 (2020). https://doi.org/10.1007/s00467-019-04310-x

Download citation


  • Disasters
  • Children
  • Crush syndrome
  • Dialysis
  • Refugee children
  • Paediatric victim