Abstract
Background
The war in the Gaza Strip and the accompanying blockade have rendered health services largely inaccessible and ineffective. Consequently, patients who rely on regular hemodialysis (HD) are at risk of morbidity and increased mortality due to medical complications related to inadequate healthcare. This study examines the war’s impact on regular dialysis patients in the Gaza Strip and their health-related quality of life (HRQOL) during the war.
Methods
In November 2024, this cross-sectional, multicenter study employed a stratified sampling method, stratified by gender and HD center, to recruit 260 dialysis patients from the four centers still operating in the Gaza Strip through a self-reported survey. IRB approval and participant written consent were obtained. The study collected sociodemographic and clinical data and examined the war’s impact on the participants. HRQOL was evaluated using the Kidney Disease and Quality of Life™ (KDQOL™-36) questionnaire. Following descriptive statistics, inferential analysis investigated the relationship between certain study variables and the various KDQOL™-36 domains. Statistical analysis was performed using R software.
Results
Most participants were unemployed and lacked a consistent income. The most common comorbidities included hypertension, cardiovascular disease, and diabetes mellitus. Participants had been receiving regular HD for a median duration of 3.4 years. Nearly half had two or fewer weekly sessions over the past month, with each session averaging three hours. Additionally, the dialysis patient population had decreased to 629 at the time of the study, down from 1100 in 2023. Most participants (81.92%) reported needing to seek healthcare outside their residential areas, and 35.00% consistently felt that accessing healthcare providers was a danger. Moreover, 41.54% experienced significant interruptions in dialysis, with a median interruption length of 8.5 consecutive days without HD. The mean scores for the Physical Component Summary (PCS), Mental Component Summary (MCS), Burden of Kidney Disease (BKD), Symptoms and Problems of Kidney Disease (SPKD), and Effects of Kidney Disease on Daily Life (EKD) domains of the KDQOL™-36 were 34.78, 34.37, 38.97, 62.50, and 50.83, respectively. Factors associated with lower scores in some or all domains included male gender, cardiovascular disease, hypertension, diabetes mellitus, osteoarthritis, having three or more weekly sessions, access via central venous catheter, HD interruptions, feeling unsafe when accessing healthcare facilities, and needing to seek healthcare outside the participants’ residential areas.
Conclusion
The ongoing war in Gaza has had a devastating impact on patients with end-stage kidney disease (ESKD) undergoing regular HD, leading to disrupted treatment, high mortality, and severely impaired HRQOL. This study underscores the urgent need for coordinated humanitarian action to restore dialysis services, ensure access to essential medications, and safeguard vulnerable patient populations in conflict zones.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12882-025-04322-w.
Keywords: Armed conflict, Gaza strip, Healthcare access, Hemodialysis, Humanitarian crisis, Resource-limited settings
Introduction
Chronic Kidney Disease (CKD) affects nearly 10% of the global population and is a major contributor to morbidity, mortality, and healthcare costs worldwide [1, 2]. Hemodialysis (HD) has extended life expectancy for patients with End-Stage Kidney Disease (ESKD) not only in high-income countries (HICs) but also in low- and middle-income countries (LMICs), where the majority of CKD patients reside [2, 3]. However, regular (maintenance) HD is invasive, resource-intensive, and time-consuming, significantly affecting patients’ health-related quality of life (HRQOL). Typical HD schedules in these settings involve three weekly sessions lasting 3–4 h each, with added burdens from vascular access complications, fatigue, sleep disorders, depression, impaired daily functioning, frequent hospitalizations, and social limitations [4–6].
As kidney replacement therapies, such as HD and kidney transplant, have shifted focus from survival to well-being, HRQOL has become a central outcome in dialysis care. It aids in identifying patient needs, guiding communication, and assessing treatment adequacy [7]. Tools such as the Kidney Disease and Quality of Life™ (KDQOL) instrument, including the KDQOL™-SF and KDQOL™-36, have been widely used for this purpose due to their brevity and reliability [6]. Validated Arabic versions have been employed in studies across the Arab world [7–14]. Factors consistently associated with better HRQOL include adequate dialysis, physical activity, employment, higher income and education levels, and male gender [9, 12, 15]. Studies in the West Bank and Gaza have also highlighted the roles of income, age, education, diabetic nephropathy, comorbidities, and polypharmacy in determining HRQOL [13, 16, 17].
Patients on regular HD are particularly vulnerable in conflict settings due to their dependence on specialized care, stable infrastructure, and uninterrupted supplies [18, 19]. For example, more than 250 dialysis patients died during the two-year conflict in Ethiopia’s Tigray region due to treatment disruptions, with mortality nearly doubling at one center from 25.5% in 2020 to 53% in 2021 during the time of war [20]. Meanwhile, survivors experienced reduced session length and frequency [20]. In Syria, 25% of patients on regular HD had at least one week-long treatment interruption, and 46% were forced to relocate multiple times to access care [21]. Similar disruptions have been documented in other conflict zones, including Sudan [14, 22].
The Gaza Strip has been experiencing a prolonged and violent war since October 2023, which marked the most recent and severe episode in the ongoing conflict with the Israeli occupation. By June 2025, the war had resulted in over 54 thousand Palestinians being killed and more than twice that number injured, and the vast majority of the population had been displaced, starved, and traumatized [23–27]. Even before the war broke out, Gaza’s healthcare system was in chronic crisis due to repeated military attacks and nearly two decades of blockade [28, 29]. The war has only worsened this crisis due to factors such as direct attacks on healthcare facilities and staff, movement restrictions, limitations on the entry of medications, the destruction of infrastructure, and staff burnout [30–36]. As a result, it is feared that for every traumatic death, there may be as many as four additional indirect deaths from starvation, disease, healthcare collapse, and infrastructure destruction [37]. Patients undergoing regular HD due to ESKD represent one of the most vulnerable groups in the midst of this healthcare crisis. Furthermore, the previously mentioned study that investigated HRQOL among patients undergoing regular HD in the Gaza Strip recruited a small number of patients and relied on data from a single center [13]. This study aims to evaluate the HRQOL and access to HD and healthcare among ESKD patients undergoing regular HD in Gaza during the 2023–2025 war.
Methods
Design, settings, and population
This cross-sectional survey, conducted between November 23 and November 28, 2024, included patients undergoing regular HD at the four centers that were still offering dialysis services in the Gaza Strip at that time. The study excluded patients under 16 years of age, those who had been on regular HD for less than a month, those with altered consciousness, those who could not read or write, and those who refused to participate.
The Gaza Strip comprises five governorates. At the time of the study, the North and Gaza Governorates were isolated by an Israeli military corridor that separated them from the Middle, Khan Younis, and Rafah Governorates to the south, further complicating the distribution of health resources. Before the war began in 2023, there were six government-run and one private dialysis centers in the Gaza Strip. In November 2024, only three of the six government HD centers remained operational, while the others were either destroyed or non-functional. These included the Al-Shifa Medical Complex HD center in the Gaza Governorate, the Al-Aqsa Hospital HD center in the Middle Governorate, and the Nasser Medical Complex HD center in Khan Younis, each equipped with 23 dialysis machines. Additionally, a field center was established later during the war at Al-Zawaida in the Middle Governorate, which included 26 machines and was also government-run.
The study settings consisted of these four operational centers. No HD centers were operational in either the North or Rafah Governorates, as both were experiencing an Israeli ground invasion at the time and had their populations displaced. The HD centers at Al-Aqsa and Nasser hospitals operated 20 h per day. The HD center at Al-Zawaida operated eight hours daily, while the Al-Shifa HD center operated eight hours every other day. These patterns reflected the population distribution and safety constraints near each center at the time, which influenced each center’s workload, as moving to another center was either difficult or dangerous for the patients. On average, each patient received three HD sessions, each lasting three hours, in November 2024.
Sample size and sampling
The list of patients receiving HD at the centers included 629 individuals, comprising 81 from the Gaza governorate, 391 from the Middle governorate, and 157 from Khan Younis governorate. The sample size was calculated using the Epi Info StatCalc tool for population surveys, with N = 629, a 95% confidence level, a 5% margin of error, and an assumed response rate of 50%. The calculated sample size was 239 participants, which was then increased by 15% to account for anticipated deaths during the study period, exclusions, and non-responders, yielding a final pre-stratification sample size of 275. Stratified random sampling was then applied based on dialysis center and gender distribution, and systematic sampling was used within each stratum. Ultimately, 260 participants completed the survey, resulting in a response rate of 94.5% (two patients had died, and the others either declined to participate or met exclusion criteria).
Instruments
The survey consisted of five sections (Supplement 1). The first section collected sociodemographic information, including age, dialysis center, gender, education, marital status, number of family members, average monthly income over the past three months, employment, and pre-war living area.
The second section examined the war’s impact on participants, gathering information such as current living area, displacement status and number of migrations, instances of injury or military detention, and damage to homes.
The third section focused on patients’ clinical status and kidney disease, covering comorbidities, dialysis vintage, and dialysis access (AV fistula or central venous catheter, “CVC”).
The fourth section addressed the war’s impact on patients’ health, access to HD, and healthcare availability. It included variables such as the average number of weekly sessions over the past month, the duration of each session, the shortest session duration experienced during the war (for at least two consecutive weeks), the longest continuous period (in days) without HD, whether the participant was hospitalized during the past month, whether the patient had to stay overnight at the dialysis center to secure a dialysis session in the past month, the need to travel to a different area to get their regular medications, and how often they felt that reaching the dialysis center was dangerous.
The fifth section comprised the validated Arabic version of the KDQOL™-36 instrument developed by RAND and the University of Arizona [8, 38, 39]. This instrument consists of 36 items divided into two categories. The first category is the SF-12, which comprises 12 question that assess the Physical Component Summary (PCS), evaluating physical health status and the ability to perform daily physical activities, as well as the Mental Component Summary (MCS), which assesses mental well-being, emotional functioning, and social role fulfillment in patients. Both PCS and MCS scores are reported as norm-based scores, standardized to a mean of 50 and a standard deviation (SD) of 10 in the general U.S. population. Scores above 50 indicate better-than-average health status, while scores below 50 reflect worse-than-average functioning. The second category includes 24 kidney-related items that assess the burden of kidney disease (BKD, items 13–16), evaluating the perceived intrusiveness and stress caused by having kidney disease; symptoms and problems of kidney disease (SPKD, items 17–28), which evaluate the frequency and severity of physical symptoms commonly experienced by CKD patients (e.g., fatigue, itching, and nausea); and the effect of kidney disease (EKD, items 29–36), which assesses the impact of CKD on daily functioning and independence [40]. Higher domain scores indicate better HRQOL, while lower scores signify poorer HRQOL and increased symptoms.
Ethical considerations
Ethical approval was obtained from the Institutional Review Board (IRB) at the Islamic University of Gaza (IUG)(approval letter number 2024/03). Administrative approval was obtained from the Department of Health Information at the Palestinian Ministry of Health (MoH). The research was conducted per the Declaration of Helsinki. Participants gave written informed consent, emphasizing confidentiality and voluntary participation. No identifying information was collected.
Statistical analysis
Numerical data were presented as mean (standard deviation “SD”) or median (interquartile range “IQR”), while categorical data were shown as frequencies and percentages (rounded to two decimal points). The responses from the study participants were used to calculate the average scores for the five main domains of the KDQOL™-36, following the guidelines provided by the tool’s developer. The associations between the scores of the five domains and the patients’ characteristics were analyzed using the independent t-test and ANOVA test. Post hoc analysis with Bonferroni correction was applied after significant ANOVA results. Statistical analysis was performed using R Studio.
Results
Cohort demographics
The mean age (SD) of participants was 52.32 (29.06), and 57.69% were male. The majority of participants (83.46%) were unemployed, and 61.92% had no regular income. The most common comorbidities were hypertension, cardiovascular disease, and diabetes mellitus (81.54%, 25.38%, and 25.00%, respectively). Participants had a median dialysis vintage of 3.4 years. Over the past month, 45.38% reported having only two or fewer weekly HD sessions, while 54.62% had three or more weekly sessions (Table 1).
Table 1.
Baseline characteristics of the study cohort
| Variable | Full cohort (n = 260) |
|---|---|
| Age, mean (SD), years | 52.32 (29.06) |
| < 50 year, n (%) | 108 (41.54) |
| ≥ 50 years, n (%) | 152 (58.46) |
| Female, n (%) | 110 (42.30) |
| Marital Status | |
| Unmarried | 59 (22.69) |
| Married | 201 (77.30) |
| Educational Level, n (%) | |
| No formal education | 15 (5.77) |
| Primary or secondary schooling | 69 (26.54) |
| High school or Diploma | 127 (48.85) |
| Bachelor’s degree or higher | 49 (18.85) |
| Employment, n (%) | |
| Unemployed | 217 (83.46) |
| Employed | 43 (16.54) |
| Monthly Income | |
| Median (IQR), USD | 0 (0-220) |
| No income, n (%) | 161(61.92) |
| 40–300 USD, n (%) | 52 (20.00) |
| 300–1100 USD, n (%) | 47 (18.08) |
| Comorbid Conditions, n (%) | |
| Hypertension | 212 (81.54) |
| Diabetes Mellitus | 65 (25.00) |
| Asthma | 5 (1.92) |
| Cardiovascular Disease | 66 (25.38) |
| Osteoarthritis | 30 (11.54) |
| Dialysis Vintage | |
| Median (IQR), years | 3.4 (1.5-6) |
| ≤ 1 year, n (%) | 51(19.62) |
| 2–3 years, n (%) | 77 (29.62) |
| ≥ 4 years, n (%) | 132 (50.77) |
| Number of Weekly HD Sessions (Past Month) | |
| 1–2 sessions per week, n (%) | 118 (45.38) |
| ≥ 3 sessions per week, n (%) | 142 (54.62) |
| Median (IQR) number of sessions per week | 3 (2–3) |
| Duration of HD Sessions (Past Month) | |
| 2 h, n (%) | 4 (1.54) |
| 3 h, n (%) | 227 (87.31) |
| 4 h, n (%) | 29 (11.16) |
| Duration of individual HD sessions in the past month, median (IQR), hours | 3 (3–3) |
|
Median total HD hours per week in the past month, median (IQR) (range 6–12 h/week) |
9 (6–9) |
| Vascular Access, n (%) | |
| Arteriovenous fistula | 213 (81.92) |
| Central venous catheter | 47 (18.08) |
Impacts of the war on participants and their access to dialysis and healthcare
Most participants (84.62%) had been displaced, with 61.15% reporting complete destruction of their homes and 8.85% sustaining injuries from the attacks. Regarding access to healthcare, 89.62% indicated that obtaining healthcare had become difficult, with 22.69% stating they constantly had to seek healthcare outside their residential areas and 59.23% sometimes having to do so. Additionally, 35.00% consistently felt that reaching healthcare providers was a danger. Moreover, 41.54% experienced significant interruptions in HD, with a median longest duration without HD of 8.5 days (Table 2).
Table 2.
Impact of the war on patients undergoing regular HD and on their access to dialysis and healthcare
| Variable | Response | n (%) |
|---|---|---|
| War-Related Impacts | ||
| Displacement due to war | Yes | 220 (84.62) |
| Imprisonment during the war | Yes | 2 (0.77) |
| Personal injury during the war | Yes | 23 (8.85) |
| Extent of home damage | Complete destruction | 159 (61.15) |
| Partial damage | 94 (36.15) | |
| No significant damage | 7 (2.69) | |
| Healthcare Access and Utilization | ||
| Hospitalization in the past month | Yes | 53 (20.38) |
| Difficulty accessing healthcare (compared to pre-war) | Yes | 233 (89.62) |
| Frequency of seeking healthcare outside the residence area | Always | 59 (22.69) |
| Sometimes | 154 (59.23) | |
| Never | 47 (18.08) | |
| Perceived danger in accessing healthcare | Always | 91 (35.00) |
| Sometimes | 126 (48.46) | |
| Never | 43 (16.54) | |
| Prolonged interruption of hemodialysis during the war* | Yes | 108 (41.54) |
HRQOL and its associations with patient characteristics
Table 3 presents the mean results of KDQOL™-36 domains. The mean scores for the PCS, MCS, BKD, SPKD, and EKD were 34.78, 34.37, 38.97, 62.50, and 50.83, respectively. The mean PCS and MCS scores were, respectively, 1.52 and 1.56 standard deviations below the norm-based average.
Table 3.
The mean score for the KDQOL™-36 instrument scales (N = 260)
| Scale | Mean (SD) |
|---|---|
| Physical Component Summary (PCS) | 34.78 (8.55) |
| Mental Component Summary (MCS) | 34.37 (9.55) |
| Burden of kidney disease (BKD) | 38.97 (20.29) |
| Symptoms and problems of kidney disease (SPKD) | 62.50 (16.66) |
| Effects of kidney disease (EKD) | 50.83 (18.16) |
Univariate analysis (Table 4) indicated that females scored significantly higher on the EKD scale than males. Certain chronic conditions were associated with lower HRQOL scores. For instance, hypertension was associated with lower PCS scores, while diabetes mellitus negatively affected EKD scores, and osteoarthritis was associated with lower PCS and SPKD scores. Meanwhile, cardiovascular disease was associated with lower scores in the PCS, MCS, SPKD, and EKD domains.
Table 4.
Associations between patient characteristics and KDQOL™-36 scales among Hemodialysis patients (N = 260)
| Domain | PCS | MCS | BKD | SPKD | EKD | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Variable | Mean (SD) | P | Mean (SD) | P | Mean (SD) | P | Mean (SD) | P | Mean (SD) | P |
| Age | ||||||||||
| ≥ 50 years | 34.48 (8.36) | 0.517 | 34.69 (9.57) | 0.515 | 38.69 (20.64) | 0.795 | 63.31 (17.44) | 0.336 | 50.75 (18.20) | 0.954 |
| < 50 years | 35.18 (8.82) | 33.91 (9.55) | 39.33 (19.85) | 61.34 (15.50) | 50.88 (18.18) | |||||
| Gender | ||||||||||
| Male | 35.03 (8.59) | 0.565 | 34.86 (9.79) | 0.323 | 39.07 (20.94) | 0.919 | 64.14 (16.33) | 0.062 | 48.01 (17.90) | 0.003 |
| Female | 34.41 (8.51) | 33.68 (9.20) | 38.81 (20.94) | 60.22 (16.91) | 54.73 (17.85) | |||||
| Employment | ||||||||||
| Unemployed | 34.47 (8.59) | 0.200 | 34.30 (8.69) | 0.267 | 38.37 (19.09) | 0.374 | 62.03 (16.70) | 0.899 | 51.70 (18.25) | 0.067 |
| Employed | 36.27 (8.28) | 36.31 (13.01) | 42.59 (25.30) | 62.26 (16.11) | 46.21 (17.34) | |||||
| Marital Status | ||||||||||
| Married | 34.72 (8.32) | 0.799 | 34.4 2 (9.50) | 0.766 | 37.10 (19.82) | 0.015 | 62.00 (16.70) | 0.373 | 49.32 (18.06) | 0.005 |
| Unmarried | 35.06 (9.32) | 34.05 (9.92) | 44.83 (20.71) | 64.19 (16.53) | 56.55 (17.63) | |||||
| Monthly Income | ||||||||||
| No Income | 34.63 (9.10) | 0.356 | 34.05 (8.62) | 0.66 | 36.60 (19.07) | 0.062 | 63.54 (17.21) | 0.212 | 52.31 (18.33) | 0.219 |
| 40–300 USD | 33.74 (7.06) | 34.04 (10.13) | 43.58 (21.53) | 58.83 (15.18) | 48.45 (16.54) | |||||
| 300–1100 USD | 35.35 (8.84) | 35.54 (12.05) | 41.71 (21.84) | 62.83 (16.46) | 48.23 (19.01) | |||||
| Hypertension | ||||||||||
| Yes | 33.78 (7.82) | < 0.001 | 34.24 (9.18) | 0.695 | 37.81 (19.20) | 0.108 | 62.10 (16.60) | 0.246 | 50.57 (18.44) | 0.618 |
| No | 39.16 (9.93) | 34.93 (11.40) | 43.82 (23.93) | 65.06 (16.84) | 52.00 (17.10) | |||||
| Diabetes Mellitus | ||||||||||
| Yes | 33.47 (7.93) | 0.138 | 33.84 (8.84) | 0.623 | 37.63 (19.02) | 0.541 | 60.12 (15.84) | 0.173 | 45.14 (16.37) | 0.002 |
| No | 35.20 (8.72) | 34.21 (9.79) | 39.33 (20.70) | 63.29 (16.88) | 52.72 (18.36) | |||||
| Asthma | ||||||||||
| Yes | 34.92 (9.54) | 0.974 | 32.03 (6.79) | 0.480 | 30.00 (17.04) | 0.306 | 65.83 (14.62) | 0.633 | 52.52 (17.03) | 0.835 |
| No | 34.77 (8.55) | 34.41 (9.60) | 39.12 (20.11) | 62.45 (16.70) | 50.80 (18.21) | |||||
| Cardiovascular Disease | ||||||||||
| Yes | 30.74 (5.69) | < 0.001 | 31.58 (7.71) | 0.002 | 35.61 (18.53) | 0.101 | 55.77 (15.62) | < 0.001 | 43.93 (14.50) | < 0.001 |
| No | 36.14 (8.92) | 35.32 (9.94) | 40.32 (20.12) | 64.75 (16.41) | 53.17 (18.70) | |||||
| Osteoarthritis | ||||||||||
| Yes | 30.21 (7.04) | < 0.001 | 36.82 (11.81) | 0.228 | 33.71 (23.21) | 0.192 | 53.40 (16.58) | 0.002 | 50.91 (15.72) | 0.969 |
| No | 35.33 (8.61) | 34.09 (9.20) | 39.63 (19.84) | 63.68 (16.33) | 50.80 (19.42) | |||||
| Hemodialysis Session | ||||||||||
| 1–2 sessions per week | 36.18 (9.33) | 0.017 | 34.72 (10.02) | 0.528 | 39.81 (22.09) | 0.563 | 63.51 (17.01) | 0.369 | 53.32 (19.46) | 0.042 |
| ≥ 3 sessions per week | 33.60 (7.68) | 34.02 (9.03) | 38.39 (18.88) | 61.60 (16.33) | 48.71 (16.72) | |||||
| Dialysis Vintage | ||||||||||
| ≤ 1 year | 36.56 (9.32) | 0.039 | 35.03 (11.32) | 0.838 | 36.23 (22.71) | 0.459 | 63.34 (15.56) | 0.388 | 49.18 (20.87) | 0.653 |
| 2–3 years | 35.81 (8.34) | 34.12 (10.55) | 38.41 (21.06) | 64.24 (17.03) | 50.36 (17.09) | |||||
| ≥ 4 years | 33.53 (8.04) | 34.33 (8.70) | 40.33 (19.32) | 61.00 (16.62) | 51.73 (17.74) | |||||
| Vascular Access | ||||||||||
| Arteriovenous fistula | 35.12 (8.60) | 0.154 | 34.77 (9.19) | 0.199 | 40.38 (19.48) | 0.071 | 63.67 (16.52) | 0.020 | 51.74 (17.82) | 0.095 |
| Central venous catheter | 33.20 (8.21) | 32.54 (10.97) | 33.52 (23.56) | 57.30 (16.41) | 46.60 (19.01) | |||||
| Hospitalization in the Past Month | ||||||||||
| Yes | 33.47 (8.62) | 0.219 | 33.57 (10.32) | 0.524 | 34.41 (20.21) | 0.068 | 58.17 (16.53) | 0.035 | 47.02 (17.00) | 0.073 |
| No | 35.10 (8.52) | 34.57 (9.36) | 40.49 (20.56) | 63.60 (16.57) | 51.82 (18.34) | |||||
| Difficulty Accessing Healthcare | ||||||||||
| Yes | 34.72 (8.64) | 0.662 | 34.18 (9.51) | 0.373 | 38.85 (20.61) | 0.631 | 62.45 (16.81) | 0.156 | 50.86 (18.03) | 0.967 |
| No | 35.50 (8.51) | 35.99 (9.87) | 40.53 (17.22) | 66.42 (14.60) | 50.75 (17.91) | |||||
| Personal Injury During the War | ||||||||||
| Yes | 33.09 (7.19) | 0.259 | 32.83 (11.61) | 0.500 | 33.41 (22.94) | 0.231 | 57.50 (15.57) | 0.121 | 46.40 (13.10) | 0.118 |
| No | 34.80 (8.56) | 34.50 (9.36) | 39.54 (20.21) | 63.06 (16.75) | 51.00 (18.51) | |||||
| Interruption of Hemodialysis During the War | ||||||||||
| Yes | 34.38 (8.56) | 0.534 | 33.30 (9.33) | 0.157 | 31.21 (20.76) | 0.452 | 60.01 (17.92) | 0.045 | 49.32 (17.01) | 0.246 |
| No | 35.03 (8.61) | 35.03 (9.60) | 39.85 (20.02) | 64.20 (15.50) | 52.07 (18.83) | |||||
| Perceived Danger in Accessing Healthcare | ||||||||||
| Never | 37.77 (9.43) | 0.024 | 36.04 (10.82) | 0.002 | 37.92 (19.00) | 0.234 | 62.06 (17.61) | 0.445 | 52.08 (19.11) | 0.785 |
| Sometimes | 34.73 (8.05) | 35.8 (9.00) | 41.13 (20.11) | 63.83 (15.35) | 51.53 (17.81) | |||||
| Always | 33.41 (8.32) | 31.06 (9.01) | 36.43 (21.07) | 61.15 (18.01) | 49.87 (18.44) | |||||
| Extent of Home Damage | ||||||||||
| No significant damage | 35.89 (9.87) | 0.929 | 40.00 (7.41) | 0.105 | 37.52 (20.00) | 0.901 | 69.66 (13.37) | 0.505 | 53.53 (17.84) | 0.917 |
| Partial damage | 34.83 (8.74) | 35.23 (10.02) | 39.76 (20.22) | 62.04 (16.28) | 50.57 (18.70) | |||||
| Complete destruction | 34.66 (8.42) | 33.61 (9.09) | 38.68 (20.59) | 62.43 (17.00) | 50.83 (17.91) | |||||
| Frequency of Seeking Healthcare Outside the Residence Area | ||||||||||
| Never | 36.82 (10.06) | 0.115 | 39.26 (12.32) | < 0.001 | 42.82 (24.23) | 0.121 | 69.02 (13.08) | 0.001 | 54.02 (20.00) | 0.024 |
| Sometimes | 34.63 (82) | 33.53 (8.70) | 36.85 (19.79) | 59.52 (16.83) | 48.07 (17.35) | |||||
| Always | 33.42 (8.34) | 32.63 (7.79) | 41.40 (17.76) | 65.06 (17.00) | 54.86 (17.79) | |||||
In terms of treatment patterns, participants receiving HD three or more times per week had lower PCS and EKD scores compared to those with fewer sessions. Use of a central venous catheter for vascular access was associated with lower SPKD scores compared to arteriovenous fistula access.
Regarding the effects of the war on HRQOL, patients who experienced interruptions in HD during the conflict reported lower SPKD scores. Those who felt unsafe accessing healthcare facilities had reduced MCS and PCS scores. Additionally, patients who needed to travel outside their residential area to reach healthcare centers were associated with lower MCS, SPKD, and EKD scores. Results of post hoc analysis are included in Supplement 2.
Discussion
This study used stratified sampling to assess the impact of the ongoing war in Gaza (since October 2023) on ESKD patients receiving regular HD and their HRQOL. Most participants had no income; nearly half received ≤ 2 weekly HD sessions, and 41.5% reported an average of 8.5 consecutive days without dialysis. The majority were displaced, with severe or total home damage, and around 80% described healthcare access as dangerous and distant. These conditions adversely affected all HRQOL domains measured by the KDQOL™-36.
It is feared that the collapse of essential healthcare services during the war has resulted in four additional indirect deaths for every violent death recorded, due to factors such as medication shortages, inaccessibility of care, dialysis interruptions, destruction of health facilities, and limited critical care capacity [36, 37, 41]. This study corroborates these concerns, noting that the number of patients on regular hemodialysis in Gaza had declined to 629 at the time of data collection, compared to 1034 and 1100 patients in 2022 and 2023, respectively [42, 43]. In June 2025, local health authorities reported that 41% of patients on regular HD in Gaza had died since the onset of the war [44]. By comparison, over 250 patients died from inadequate dialysis during two years of conflict in Ethiopia’s Tigray region [19, 20]. The sharp decline in dialysis patients in Gaza is thus unprecedented, reflecting the devastating impact of the conflict on this vulnerable population through direct attacks, infrastructure destruction, treatment disruption, displacement, and malnutrition. Moreover, approximately 450 kidney transplant recipients in Gaza have faced prolonged interruptions in immunosuppressive therapy due to medication shortages, placing them at imminent risk of graft rejection. With transplant surgeries likely halted and no access to follow-up care or dialysis backup, their outcomes have likely mirrored or exceeded those of HD patients [45].
Adequate dialysis significantly improves both survival and HRQOL, whereas inadequate dialysis is associated with increased mortality, malnutrition, inflammation, accelerated atherosclerosis, and reduced HRQOL [12, 46]. Dialysis adequacy depends on multiple factors, particularly the frequency and duration of HD sessions [12]. According to the 2015 KDOQI guidelines, patients with minimal or no residual kidney function should receive HD three times per week, with a minimum of three hours per session [47]. In this study, most patients received only 6–9 h of HD per week, which is substantially below the recommended minimum, and just 54.62% received three or more weekly sessions. Similar patterns of treatment disruption have been reported in war-affected regions such as Sudan [14]. It is also noteworthy that this study was conducted a year into the war, whereas the early months witnessed the most severe destruction of healthcare infrastructure, suggesting that session lengths and frequencies were likely even lower at the onset of the conflict, further contributing to the suffering and excess mortality among dialysis patients.
The means of KDQOL™-36 domains reported in this study are lower than those reported in previous studies from Palestine and other countries. For instance, the mean scores for the PCS, MCS, BKD, SPKD, and EKD were 34.78, 34.37, 38.97, 62.50, and 50.83, respectively, in the present study. In comparison, a 2023 multicenter study in the West Bank reported higher scores (indicating better HRQOL) across all five domains (47.10, 41.15, 66.03, 44.21, and 61.88) [16]. Another study from Sudan also reported similar findings with even higher means (44.1, 36.8, 74.5, 49.6, and 62.7, respectively) [8]. A third study from Saudi Arabia similarly reported higher means in three out of five domains (63.5, 57.2, 49.2, 67.2, and 46.5, respectively) [10]. This consistent finding illustrates the impact that the war in the Gaza Strip had on the HRQOL of dialysis patients.
This study did not identify any significant associations between the KDQOL™-36 domains and certain baseline characteristics of the cohort, including age, employment status, and income level. These findings contrast with those from a previous study conducted in the West Bank, Palestine (Naseef et al., 2023), which reported that older age and lower income were associated with lower KDQOL™-36 scores [16]. The lack of such an association in our study may stem from the unique humanitarian conditions in Gaza, which impacted all individuals, regardless of their economic or social status. This widespread humanitarian hardship may have diminished the influence of sociodemographic factors on HRQOL.
On the other hand, comorbidities showed a strong negative association with the KDQOL™-36 domains, with at least one domain being adversely affected in the presence of hypertension, diabetes mellitus, cardiovascular disease, or osteoarthritis. Among these, cardiovascular disease had the most pronounced impact on HRQOL in this cohort. This finding aligns with a 2016 study by Barham et al. in the West Bank, which demonstrated that Palestinian patients with coronary heart disease experienced significantly lower HRQOL compared to counterparts in China and Switzerland [48]. Similarly, a previous study in Palestine found that patients with diabetic nephropathy reported lower HRQOL compared to non-diabetic dialysis patients [16].
Regarding treatment patterns, an inverse relationship was observed between dialysis frequency and HRQOL, with patients receiving two or fewer sessions per week scoring higher in the PCS and EKD domains than those receiving three or more sessions. Although counterintuitive, this may reflect that patients undergoing more frequent dialysis often have more advanced disease and greater comorbidity burden, necessitating emergency sessions and contributing to reduced physical function and daily limitations. Conversely, those on fewer sessions may have better residual kidney function or fewer health complications, resulting in higher perceived physical and functional well-being despite receiving suboptimal care.
Additionally, the use of an arteriovenous fistula (AVF) was associated with better outcomes in the SPKD and BKD domains. In contrast, a 2023 study by Naseef et al. in West Bank hospitals found no association between dialysis frequency or vascular access and HRQOL [16]. This discrepancy may stem from unmeasured confounding variables. However, supporting the present findings, a large Korean study involving 1,461 patients reported that those with AVFs had lower mortality and fewer access-related complications, which contributed to improved HRQOL outcomes [49].
The ongoing conflict in Gaza has profoundly impacted the HRQOL in the study cohort. The perceived danger of accessing healthcare facilities may have increased stress and anxiety among patients, leading to lower scores in both the PCS and MCS domains. This finding aligns with a study conducted in Somalia, which indicated that anxiety, as measured by the Hospital Anxiety and Depression Scale, was negatively associated with the HRQOL in patients undergoing regular HD [50]. Furthermore, the necessity of seeking healthcare outside residential areas was also linked to a decline in the MCS, SPKD, and EKD domains. This reflects the emotional, physical, and logistical challenges patients are compelled to navigate.
The study has several limitations. First, the exclusion of illiterate patients may introduce selection bias and limit the generalizability of the findings, although literacy in Gaza is high (the adult literacy rate is nearly 98%), which may mitigate—but not eliminate—the effect of this criterion on representativeness. Second, the study may be subject to survival bias, as the most severely ill patients may have died during the initial, more intense months of the war, prior to data collection. Third, the study relied on self-reported data regarding dialysis interruptions, which may be subject to recall bias. Fourth, although the study utilized a validated tool and robust sampling methods, some important dimensions of HRQOL, such as anxiety, depression, and trauma-related symptoms, may not have been fully captured and would benefit from assessment using more specialized psychological instruments. Lastly, the cross-sectional design limits the ability to make causal inferences. Future research is encouraged to adopt longitudinal approaches and incorporate broader assessment tools to better understand the long-term impacts of conflict on this population.
Conclusions
This study provides critical insight into the profound impacts of the ongoing war in Gaza on patients with ESKD undergoing regular HD and their access to HD and healthcare. The findings reveal severely compromised dialysis adequacy, widespread displacement, and limited access to care. It also reports on their significantly impaired HRQOL across all KDQOL™-36 domains. The exceptionally high mortality among dialysis patients, compounded by treatment disruptions and systemic collapse, underscores the urgent need for sustained humanitarian and medical intervention. Beyond quantifying clinical outcomes, this study highlights the broader human toll of conflict on vulnerable populations and calls for immediate, coordinated efforts to restore essential healthcare services, protect patients with chronic diseases, and prioritize kidney care in crisis settings.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Author contributions
BA conceptualized the study. All authors contributed to the literature review and the development of the study tool. BA supervised the study. BA performed participant randomization. All authors except the second author collected the data. BA and AE analyzed the data and led the writing of the manuscript. All authors contributed to the manuscript revision and have approved the final draft.
Funding
The study was not funded.
Data availability
Available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval was obtained from the Institutional Review Board (IRB) at the Islamic University of Gaza (IUG). The research was conducted in accordance with the principles outlined in the Declaration of Helsinki. Informed written consent was obtained from the patients. No identifying information was collected, and anonymity was guaranteed.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Supplementary Materials
Data Availability Statement
Available from the corresponding author upon reasonable request.