People with kidney failure undergo routine dialysis twice or thrice a week. But when the situation becomes extremely dangerous to even step out — not to mention the shortage of electricity, water etc. — like in Gaza, some extreme measures may help tide over the emergency.
“A person on routine dialysis spends about 12 hours per week undergoing dialysis. This could be split into four hours, three times a week, that is, every alternate day, or six hours, twice in a week,” says Dr Sankaran Sundar, director, Aster Institute of Renal Transplantation, Aster Whitefield, Bangalore. “Purified water and uninterrupted electricity are crucial to perform dialysis,” he adds.
Both are in short supply and nephrologists have already sounded the alarm on the plight of people requiring routine kidney dialysis in the region.
According to Dr Atul Ingale, consultant nephrologist and transplant physician, director, department of nephrology, Fortis Hiranandani Hospital, Mumbai, says people needing dialysis three times a week can prolong it for a day and no more. If on dialysis twice a week, they can prolong for 5-6 days. Moreover, a person who needs dialysis once a week can function without it for up to 10 days as their kidneys are in much better condition.
“How one may get affected if they miss dialysis sessions also depends on a person’s kidney function. However, in my opinion, missing more than 72 hours of dialysis is dangerous for someone undergoing routine or regular dialysis. It can even be life-threatening,” says Dr Sundar. He adds that when a person misses dialysis for any reason, they should exercise caution with their diet and water intake. “If they drink excess fluids, it may go into their lungs and could even be fatal,” explains Dr Sundar.
Temporary precautions while missing dialysis
Dr Sundar points out some temporary but crucial measures that an individual can take when unable to undergo dialysis.
- Limiting fluid intake to 500 ml per day. This includes not only water but also foods with water content.
- Avoiding most vegetables and fruits as they contain water. Cucumber, especially, has a high water content. People can opt for rice, chapati (bread) or egg whites instead.
- Restricting the intake of fluid, salt, and potassium temporarily.
What happens when you delay dialysis?
Once on dialysis, most individuals will not pass much urine. They may pass 100–200 ml per day, says Dr Sundar. He adds that when dialysis is made unavailable, the person suffers from fluid retention.
“The kidney is the exhaust system of the body. When it gets blocked, the body gets affected.” reminds Dr Ingale. Thus, without dialysis, the condition of those requiring regular dialysis is bound to deteriorate. This results in the accumulation of toxins, fluids and acid. A person can function with the accumulation of toxins for two to three days but not with the accumulation of fluids and acid as breathlessness can set in, and they need to be rushed to the hospital,” he said.
Gaza: Fewer dialysis sessions for now
With access to purified water dwindling, crucial medications running out and electricity supply being severely hit, several people requiring routine kidney dialysis have been left in the lurch, say doctors.
Several such people have either relocated to other cities or are in distress, suffering from fluid overload.
“We are truly living through a disaster,” Dr Hammam M Alloh, a nephrologist working in Gaza city, tells Happiest Health. The current situation is a lesson in “disaster nephrology management”, adds Dr Alloh, who works at Aqsa Martyrs and Shifa hospitals — both in Gaza.
In addition to reducing sessions for those requiring routine dialysis by nearly half, hospitals in Gaza are finding it difficult to supply immunosuppressant medications for kidney transplant recipients, people with chronic kidney disease (CKD) and those with nephrotic syndrome.
Dr Alloh says the doctors decided to cut the dialysis hours by nearly half as it is the best course of action in the current scenario. However, this makeshift solution can work for a couple of weeks only.
“But longer than that, those requiring dialysis will start to suffer,” he says. “The dialysis will be inefficient, individuals will start suffering from fluid overload — and there will be more urgent need for hemodialysis. There will be a higher requirement for more equipment — like dialyzers and other devices — of which we are already facing a shortage.”
Dr Alloh says in the current scenario, doctors are unable to offer complete hemodialysis sessions for those who experience weight gain in between sessions.
“Another issue is the supply of purified water for dialysis and electricity supply,” he says. “Soon, there will be electricity shortage all over Gaza Strip. This spells danger in a few days for people who are dependent on regular hemodialysis. Most of these patients have very poor residual kidney function.”
Gaza hospitals: From infectious diseases to trauma
“A lot of people are currently residing in the hallways of dialysis units all over Gaza hospital wards,” Dr Alloh says. “Many are sleeping here.”
He adds that due to the poor hygienic conditions owing to the war, a lot of people are now also presenting with infectious diseases like leptospirosis.
The doctor says that persons with trauma are also liable for blood loss for hypertension, perennial acute kidney injury and rhabdomyolysis-associated acute kidney injury (a type of kidney injury requiring hemodialysis). This only adds to the burden of dialysis insufficiency in terms of equipment and the number of machines, he says.
Dr Alloh explains that the hospitals are unable to provide all the doses of medications that kidney transplant recipients and people with CKD need — because no medications have entered Gaza through its borders for more than 10 days now.
“Those on hemodialysis and with CKD are already facing a shortage of supplies, including medications such as the ones used to treat anemia associated with CKD,” he says.
Gaza is also facing a shortage of medicines such as calcimimetics, which is used to treat secondary hyperthyroidism in people undergoing dialysis.
Similar circumstances: Gaza and Sudan
The situation in Gaza is similar to the one Sudan has been facing for the past six months — ever since a civil war started in the African nation in April 2023.
Dr Hisham Hassan Abdelwahab, immediate past president of the Sudanese Society of Nephrology, says a lot of dialysis units are shut down in times of war and people start reducing the frequency of dialysis.
“The average dialysis frequency for a person with CKD is thrice a week,” he says. “In the event of crisis and closure of dialysis centers, one may end up doing sessions only once or twice a week. This will badly affect their health. The longer you delay dialysis, the more the toxins accumulate. It’s a very serious problem.”
During particularly violent clashes lasting nearly two weeks recently, all those in the dialysis unit in a region in Sudan died due to lack of access to dialysis, according to the doctor. He fears a repeat of such a situation in Gaza, too.
“In Sudan, the war has been going on for the past six months,” says Dr Abdelwahab. “Most of those on dialysis have fled the towns where the war is going on — the capital city [Khartoum] and some of the western cities. They have migrated to other cities where there are no clashes.
“A lot of the dialysis centers have become very crowded due to this. In place of four-hour dialysis sessions, patients are now getting only two-hour dialysis sessions in most of these centers.”
Dr Abdelwahab adds that the cornerstone of all dialysis units is electricity. “If you cut down the power, the machines will not work and no dialysis will happen — especially if you don’t have generators.”
So, until peace is restored, the electricity crisis itself poses a life-and-death challenge in both Sudan and Gaza.
In war-stricken Gaza, nephrologists have cut down dialysis sessions by nearly half for those on regular dialysis. Hospitals are also struggling to supply immunosuppressant medications for kidney-transplant recipients and for people with CKD and nephrotic syndrome. Desperate times call for desperate measures and doctors suggest reducing fluid, salt and potassium intake to extend the time between dialysis sessions as a mitigating measure.