Nephrology Care in Ukraine: Almost 2 Years of Wartime Experience

War, even when anticipated, inevitably unfolds unexpectedly, as evidenced by the situation in Ukraine.¹ The effect of war is multifaceted, affecting two distinct groups of victims: military personnel and the civilian population. Military personnel face the risk of developing new diseases, exacerbation of chronic conditions, and injuries resulting from military activities. Simultaneously, the civilian population contends with the consequences of both acute and chronic diseases, further emphasizing the wide-reaching implications of armed conflict on public health (Figure 1).²

Figure 1.

Groups of victims as a result of military operations.

In alignment with UN data, the effect of military operations on Ukraine's population has been severe, with a decrease of more than six million people,³ including 25% being children. As of the second half of 2023, the humanitarian situation remains dire, with 3.7 million internally displaced individuals, 17.6 million in need of humanitarian assistance, and 8.3 million actively receiving such assistance.⁴

In the broader context of medical care provision, patients with kidney diseases, constituting approximately 10% of the population, emerge as a significant and vulnerable group. Notably, data on patients undergoing RRT during martial law are crucial. In 2019, before the conflict, there were 11,940 patients with CKD stage 5 in Ukraine, necessitating dialysis or transplantation. However, by October 2023, this number had decreased to 10,748. The displacement caused by the conflict is evident, with 602 Ukrainian refugees requiring dialysis relocating to the European Union in the first 6 months of hostilities⁵ and more than 400 remaining in territories temporarily beyond Ukraine's control. Notably, more than 1009 patients from the prewar registry, who were on dialysis or had transplants, are unaccounted for.

Amid the military situation in 2022, logistical challenges prompted the transition of 22 individuals from automated peritoneal dialysis (PD) to hemodialysis. In addition, ten individuals underwent transplantation while unfortunately, 56 patients lost their lives. As of the end of October 2023, 29 patients shifted from automated PD to hemodialysis, 15 received transplants, and 54 succumbed to the challenges of the conflict. Presently, 305 patients in Ukraine are undergoing manual PD while 206 are receiving automated PD.

To manage kidney care effectively during hostilities, four distinct zones were delineated on the basis of their characteristics and capabilities in providing such care. This strategic approach recognizes the varying challenges and opportunities in different regions, aiding in the efficient allocation of resources (Figure 2).⁶

Figure 2.

Classification of Ukrainian territories during martial law in 2022.

This snapshot provides a sobering overview of the profound impact of the conflict on the kidney health landscape in Ukraine, emphasizing the urgency of targeted interventions and international support in addressing the complex health care needs arising from the ongoing crisis.

The absence of available data on kidney conditions among military personnel underscores a critical gap in our understanding of the overall health effect on this specific demographic during the conflict. However, the focus shifts to three key zones crucial for the civilian population, each presenting unique challenges and opportunities.

1. Areas where assistance cannot be provided:

   • Regions: Luhansk, Donetsk, partially Kharkiv, Kherson, and Zaporozhye

   • Situation: These areas face severe limitations in providing assistance, likely due to the ongoing conflict and associated challenges. Access to health care resources, including kidney care, is constrained, posing significant threats to the health and well-being of the population.

2. Regions with limited possibility of providing kidney care:

   • Central part of Ukraine

   • Situation: The central part of Ukraine experiences constraints in delivering kidney care, likely due to logistical and operational challenges arising from the conflict. While care may be available, it is limited, presenting a spectrum of weaknesses and potential threats to health services.

3. Territories where kidney care capacity has been preserved or expanded:

   • Western Ukraine, with a specific emphasis on Lviv

   • Situation: In contrast to the aforementioned zones, Western Ukraine, particularly Lviv, has managed to preserve and even expand kidney care capacity compared with the prewar situation. This region showcases strengths and opportunities in maintaining and enhancing health care services amid challenging circumstances.

The second significant factor influencing the organization of kidney care is the evolving timeline of military operations.⁷ The identification of distinct periods (referenced in Figure 3)⁶ allows for a structured evaluation using the Strengths, Weaknesses, Opportunities, and Threats analysis framework. Each period is assessed for internal and external factors that affect kidney care, providing a comprehensive understanding of the dynamic landscape shaped by the progression of hostilities.

Figure 3.

Timeline in Ukraine.

The onset of war introduced a myriad of stressors that significantly affected the provision of kidney care in Ukraine. The negative factors, universal to military conflicts, persisted throughout the entire duration of the military operations.⁸ These factors included the following:

1. Stressors from war outbreak:

   • Lack of recommendations for patients with CKD.

   • Challenges in providing care to acute patients amid limited resources.

   • Scarcity of essential resources such as food and water.

   • Inadequate bomb shelters, posing a threat to the safety of the population.

   • Inability to reach bomb shelters, exacerbating the risks.

   • Lack of information about the evolving situation.

   • Loss and disability of loved ones.

   • Social maladjustment and disrupted communication.

These stressors, to varying extents, characterized the challenging environment during the entire period of military operations. Although these factors exacerbate the limitations of resources for medical care, the article emphasizes that consensus recommendations from experts can play a crucial role in managing and mitigating these challenges.⁹

1. Impact on medical staff:

   • Variation in the number of medical staff and their ratio to the population across regions.

   • In the first 3 months of the war, up to 40% of medical personnel in the southeastern parts of Ukraine left, contributing to a significant health care workforce shortage.

   • By contrast, the western region saw an increase in the number of doctors and nurses, although the proportion was smaller.

2. Transition to virtual health care:

   • Disruption of physical communication between patients and doctors in the early months of hostilities.

   • Emergence of virtual health care and virtual kidney care as adaptive responses.

   • Provision of consultations through messaging platforms such as Viber and WhatsApp.

   • Monitoring of patients through video communication within Ukraine and for emigrants abroad.

   • Adoption of conference calls as a norm during military operations.

The transition to virtual health care became a vital strategy to overcome communication barriers and ensure continued care delivery despite the challenging circumstances. These adaptations underscore the resilience of the health care system in responding to the dynamic needs arising from the conflict.

The transition to virtual health care emerged as a crucial strategy to overcome communication barriers, ensuring the continuity of care delivery despite the challenging circumstances. This adaptive measure underscores the resilience of the health care system in responding to the dynamic needs arising from the conflict. However, several other factors negatively affected the capacity for kidney care.

1. Logistical disruptions:

   • Challenges in transportation for patients to reach their treatment locations.

   • Disruptions in the provision of medical drugs and consumables for dialysis.

   • Most significant in the first 3 months, causing panic, misunderstanding, and despair.

2. Supply shortages:

   • Reduction in the quantity of care provided.

   • Decrease in the number of available medications.

   • Contributed to a notable increase in BP (18%–24% for systolic blood pressure and 12%–17% for diastolic blood pressure on the basis of local data on 912 patients).

   • Limited possibilities for BP management.

3. Humanitarian relief:

   • Necessity to accept humanitarian relief, primarily from the European Union and the United States.

   • Critical in mitigating the effect of supply shortages and ensuring the availability of essential medical resources.

4. Blackout challenges:

   • Dialysis centers and hospitals classified as critical infrastructure facilities, mitigating significant negative consequences for most patients.

   • Some hospitals had to stock up on water and use electric generators.

   • Outpatients receiving PD with cyclers had to reduce dialysis time in certain areas.

   • Situation stabilized within a month after the delivery of recharging stations, the use of electric generators, and the transfer of some patients to hemodialysis.

5. Classification of negative factors:

   • Detailed analysis presented by international experts.

   • Classification of negative factors into those that can be modified or managed and those that cannot be significantly modified and managed.¹⁰

International expert groups, particularly the ERA Renal Disaster Relief Task Force; specialized nephrology associations, primarily the German Society for Pediatric Nephrology, the German Society for Nephrology, and the Board of Trustees for Dialysis and Transplantation; personal support, for example, professors Elena Levtchenko, Lionel Rostang, and Lutz Weber; and humanitarian programs, such as Direct Relief, made a huge contribution to maintaining the quality and possibilities of providing nephrological care in Ukraine.

The adverse effects of military actions have spurred adaptation among civilians, health care professionals, and medical personnel to the challenges posed by war. This adaptation has given rise to a series of positive initiatives aimed at enhancing kidney care. Initially, the disruption of communication between patients and doctors in the early months of hostilities led to the emergence of virtual health care and virtual nephrology. The Ukrainian Association of Pediatric Nephrologists and the Ukrainian Association of Nephrologists played pivotal roles in restoring communication with patients and organizing kidney care.

Initiative groups were established on messaging platforms such as WhatsApp, Viber, or Telegram, serving as crucial communication hubs primarily for doctors. Another unifying factor was the uninterrupted publication of the Ukrainian medical journal KIDNEYS, complemented by ongoing annual training courses on the Accelerator of Medical Information web platform Accemedin. This platform, created in Ukraine for professionals in the medical field, has garnered more than 70 thousand views among all doctors in Ukraine, reflecting extensive engagement.

These collaborative efforts underscore the resilience and adaptability of the medical community, demonstrating its commitment to overcoming communication challenges and sustaining educational initiatives amid the disruptions caused by wartime conditions.

Second, existing challenges in diagnosis and treatment prevented the sending of any biological samples abroad, for genetic analysis particularly, and led to the intensification of nephrobiopsies with immunohistochemical analysis (44 biopsies). A digital model involving cloud technology was used, kidney biopsy is conducted and processed locally in Kyiv, and the reading of the biopsies is performed using a digital model. As a result, through this new service, one laboratory in Kyiv performed more kidney biopsies than all of Ukraine in the prewar period.

Third, difficulties for patients receiving in-hospital cyclophosphamide pulses, the impossibility to monitor serum concentration of cyclosporine A/tacrolimus because of limited resources, and the lack of a sufficient mycophenolate mofetil prompted the use of rituximab for patients with glomerulonephritis, which was received through humanitarian aid. This made it possible to reduce the burden on nephrologists, gain new experience, and, more importantly, to achieve significant positive results in patients: 18 patients with progressive glomerulonephritis (15 from them were biopsied) and seven children with frequently relapsed nephrotic syndrome. The positive effect with decreasing proteinuria from 2.1±0.3 to 0.3±0.1 was obtained 13 patients (72%) in 1-year treatment. All children with relapsed nephrotic syndrome have remission. Noteworthy remission was also attained in patients with membranous nephropathy and lupus nephritis of morphological class 4. The total number of rituximab infusions increased 4.5 times compared with prewar times.

Fourth, significant success has been achieved in people receiving RRT. In the first 3 months from the start of the war, hemodialysis care was significantly limited in the northern and western regions of Ukraine. In this regard, the incremental dialysis were used, and for patients who were already receiving dialysis, extended hemodialysis was initiated with target level of Kt/V of at least 1.2. These modalities made it possible to practically avoid additional mortality. Starting from 4 months of the military conflict, the logistic chains were restored, and there were practically no restrictions in the provision of hemodialysis for a long time, with the exception of short-term problems with water and electricity, which, as noted above, was quickly resolved because hemodialysis centers were considered a priority of infrastructure facilities. Moreover, there was a surplus of dialysis beds because of a general reduction in the number of dialysis patients, which continues to the present day. At the same time, the practice of using incremental and extended dialysis has remained as an additional option in providing patient care. These approaches made it possible to individualize dialysis therapy and prevent a significant increase in mortality.

Transplant activity also increased by more than 60% in adults and almost doubled in children. Genotyping of donors and recipients, determination of donor-specific antibodies, and virtual cross-matching are implemented in transplant centers, and simultaneous transplantation of kidneys and pancreas has been started. Modern technological processes have been implemented (laparoscopic and robotic (DaVinci) donor nephrectomy, Cell-saver for significant bleeding, Kidney-assist, etc.). All patients undergo HLA typing and cross-match before transplantation. In 2021, there were 231 kidney transplants, with 126 from living donors, including 28 involving children. In 2022, the numbers increased to 274 kidney transplants, including 134 from living donors (source: https://utcc.gov.ua/statystyka/). Notably, there has been a shift in the territorial activity of transplantations toward safer regions. In 2023, among the 24 transplant centers in Ukraine, Lviv led in kidney transplants, surpassing Kyiv. The dynamics in Lviv for the years 2021–2023 are as follows: 0 children and 48 adults in 2021, three children and 75 adults in 2022, and 15 children and 79 adults in 2023.

Thus, long-term military operations in large territories in Ukraine significantly affected the provision of kidney care, particularly to people with CKD. According to our experience, the most severe negative effect occurred in the first months of the war. Given that Ukraine had a relatively robust nephrology services before the war, we were able to rebound and innovate as a community quite fast. To improve resilience under conflict conditions, it is important to train and educate personnel, promote knowledge of the management of emergencies in people with CKD, to prepare premises, to stockpile medicines and consumables, and to prepare communication links and external networks for support. We hope that dissemination of our experience at the global level may be of use to others in the nephrology community.

Disclosures

D. Ivanov: Employer: Consultancy: AstraZeneca, Bayer, and Sandoz.

Funding

None.

Author Contributions

Conceptualization: Dmytro Ivanov.

Writing – original draft: Dmytro Ivanov.