Renal Replacement Therapy in Poland and Lifesaving Treatment for Ukrainian Refugees: Coping With the Humanitarian Crisis

Based on data by the World Population Review and taking into consideration that 10% to 15% of the world’s population is having any stage of chronic kidney disease (CKD), it can be estimated that approximately 4 to 6 million Ukrainians with kidney diseases may be affected by the recent armed conflict.1 Of relevance, patients with CKD, particularly those with end-stage renal disease (ESRD), require special attention because their survival critically depends on a functional medical infrastructure, including dialysis facilities, specialized treatment, expertise, and access to transplantation.2 In 2021, there were >11 000 patients on renal replacement therapy (RRT) in Ukraine, including >1500 kidney transplant (KTx) recipients; 6000 patients have been on hemodialysis (HD), 2700 on hemodiafiltration, and almost 1000 on peritoneal dialysis (PD).3 It has been previously reported3 that Ukrainian patients on RRT receive prioritization for immigration into European Union countries, where they will be able to receive dialysis. Since the start of the war in Ukraine (February 24, 2022), >8 Mio citizens of Ukraine have crossed the Polish border, whereas almost 6 Mio Ukrainians returned to their home country. The Polish Ministry of Interior Affairs estimates that there are currently (December 2022) approximately 2 Mio Ukrainian refugees in Poland. Refugees requiring medical care, including hospitalization, are treated in accordance with the rules that apply to Polish citizens. All relevant information related to medical support is provided on the website of the Ministry of Health (https://www.gov.pl/web/zdrowie/pomoc-medyczna-dla-ukrainy) in both languages (Polish and Ukrainian). Moreover, job offers for healthcare professionals are posted bilingually (https://www.nfz.gov.pl/aktualnosci/aktualnosci-centrali/praca-dla-medykow-z-ukrainy-w-polsce-informacji-udziela-infolinia-nfz,8165.html#tlumaczenie%20na%20jezyk%20ukrainski). In addition, there is a bilingual website dedicated to patient information and support (https://pacjent.gov.pl/tag/pacienti-z-ukraini). Immigrants can also obtain a Polish Identification Number (PESEL) and have support to get basic medical drugs in pharmacies with a paper prescription. The Polish National Health Fund covers all costs for dialysis services for Polish citizens in both public and private dialysis units. Likewise, RRT for Ukrainian refugees is provided free of charge. Poland also provides vaccinations, including for coronavirus disease 2019 (COVID-19), to all refugees upon entry to Poland. All relevant information is provided on the website of the Ministry of Health in Ukrainian (https://www.gov.pl/web/ua). From the very first days of the humanitarian crisis in Ukraine, Polish hospitals accepted refugees requiring not only RRT but also any medical support requiring hospitalization and immediate therapy. A case report may illustrate our efforts: a 32-y-old female refugee had been under the care of nephrologists in her home country Ukraine since the age of 6 because of recurrent urinary tract infections and was initiated on HD in 2011. With issues creating an arteriovenous fistula and limited HD success, she was started on PD in 2012. With recurrent peritonitis, she was started on HD again in November 2021 using a temporary line. As a refugee, she was admitted to our hospital with symptoms of an upper respiratory tract infection in addition to severe abdominal pain in April 2022. Antibiotic therapy with amoxicillin was initiated. Upon admission and subsequent PD, a cloudy fluid was obtained. Cultures obtained from the PD fluid were negative. Nevertheless, with a highly elevated white blood cells count in her PD fluid, we removed the PD catheter. Surgery and radiology were consulted to discuss alternative options for vascular access. In the meantime, a tunneled cuffed catheter was implanted. Laboratory tests revealed hepatitis C virus antibodies, presence of the hepatitis B surface antigen, and highly elevated parathyroid hormonr levels (1625 pg/mL). From June to September 2022, the patient was treated successfully with ritonavir, ombitasvir, and paritaprevir with an absence of hepatitis C virus RNA on subsequent blood work. Because of advanced secondary hyperparathyroidism, she was started on cinacalcet. At the same time, she was evaluated as a transplant patient and placed on our waitlist. Another case is of a 29-y-old female refugee, with a body mass index of 18 kg/m2, in whom arteriovenous fistula on the left forearm was created in 2017. Her arterial hypertension was treated effectively with 2 agents (carvedilol and valsartan). She started HD in 2009 in Ukraine because of glomerulonephritis-focal segmental glomerulosclerosis (after 3 y of steroid therapy). The patient came to Poland in March 2022 without any medical documentation. After a thorough evaluation, she was waitlisted on November 25, 2022, with panel reactive antibody of 7%. She received an offer on December 24, 2022 (4/6 match) and was successfully transplanted on December 25, 2022, with an immediate kidney function. Her creatinine was 1.36 mg/mL 4 d after transplantation. Table 1 provides data on the RRT in Poland (2019–2021). During the COVID-19 pandemic, we “lost” 8.5% of our patient population (1832) on dialysis. This unfortunate outcome, at the same time, provided “room” to accommodate additional patients. The majority of ESRD patients in Poland are treated with HD.4 The rate of PD has seen a downward trend over the years, with 4% of the ESRD population in 2021 receiving PD. Among the overall ESRD population, 56% are aged >65 y, and 25% are aged >75 y; 28% are diabetic. At the end of 2021, 18 479 patients were on HD in 98 public and 180 private units. In addition, 890 patients were on PD (49 in public units and 31 in private units); data were retrieved from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) registry.5,6 Elective patients with CKD may be enrolled for dialysis or for preemptive KTx. The decision of the type of dialysis proceeds with input by the patients’ nephrologist. The so-called crash-landers usually commence HD with central venous catheters. Patients who are suitable for preemptive listing or those who have already started dialysis are referred to “transplant teams” with experience and qualification to place patients on the National Waiting List. With the completion of the evaluation process, the nephrologist in charge of the dialysis unit will submit the need to enroll patients to the National Waiting List, which is under the auspices of the Polish Transplant organization “Poltransplant”—supervised by the Minister of Health. During the evaluation process, patients are observed by a multidisciplinary team that includes expertise from nephrology, cardiology, surgery, dentistry, ophthalmology, laryngology, urology, and, in women, gynecology. Additional consultations may be necessary based on patients’ comorbidities. There are 22 centers in Poland qualified for listing adult and 1 for pediatric renal transplant recipients. Imaging diagnostics, laboratory results, and reevaluations are updated while patients are listed. All data are available to every center before transplantation. TABLE 1. - Patients on renal replacement, waiting list, and transplanted in Poland (2019–2021) 2019 2020 2021 Delta 2019/2020, n/% Delta 2020/2021, n/% Total number of dialyzed patients (December 31), n 21 479 19 647 19 416 –1832/–8.5 –231/–1.2 Total number of patients on HD (December 31), n 20 555 18 847 18 592 –1708/–8.3 –255/–1.35 Total number of patients on peritoneal dialysis (December 31), n 920 820 824 –100/–10.9 +4/+0.5 Total number of kidney transplants (December 31), n 959 748 753 –211/–22.0 +5/+0.7 HD, hemodialysis. The median total number of patients waitlisted during the most recent 5-y intervals has been 2638 (range, 2058–2747), with 1038 (range, 984–1196) patients having been listed actively. During the same time period, there was a median of 1066 (range, 750–1178) new enrollments to the list per year. Out of those, there was a median of 100 (range, 94–116) nondialyzed patients per year. Annually, there was a median of 42 (range, 17–54) preemptive transplantations. The mean age of patients on the waiting list was 48.1 (45.8–51) y. The median time for the first KTx since enrollment was 366 (range, 330–442) d.7FIGURE 1.: Number of organ transplantations performed in Poland in 2021.The majority of the kidneys are procured from donors after brain death (DBDs), with a very small contribution of donors after circulatory death. The median ratio of DBDs/donors after circulatory death in the last 5 y was 99.2/0.8 (range, 98.7/1.2–100/0). The median annual number of KTx alone was 924 (range, 748–1060) grafts. Out of those, there was a median of 44 live donor KTx (range, 31–56), reflecting 4.8% of all transplantations. In 2021, there were 753 kidneys transplanted from DBDs (18.5 grafts per million citizens) and 44 LD KTx’s (1,1 per million citizens)7 (Figure 1). One-, 5-, and 10-y recipient survival rates were 95%, 88%, and 74%, respectively. For 1-, 5-, and 10-y grafts from deceased donors, survival rates were 90%, 77%, and 59%, respectively. For 1-, 5-, and 10-y grafts from living donors, survival rates were 95%, 89%, and 71%, respectively.7 By the end of 2022, there were almost 300 refugees on HD and 10 on PD, and >100 KTx recipients are followed. The majority of the ESRD patients had 1 or more runs of dialyses during their journey in other countries (Germany, Sweden, France, United Kingdom, Israel, Canada, United States, or others). In our hospital we dialyzed 32 HD in total and 1 PD. Now we have 7 prevalent HD patients by the end of November 2022 (8% of our population, whereas, in Poland, refugees are 2% of the whole population on dialysis), 3 of them started the process of evaluation for KTx. In addition, there were >200 hospitalizations at the department from February 24, 2022. We consider ourselves fortunate because some of our healthcare providers speak both Ukrainian and Russian languages. Early on during the war, we also had the support of Ukrainian medical students/residents at our university. Since February 2022, we had 25 brain-dead donors of Ukrainian citizenship; 5 Ukrainian patients received renal transplants (Prof Artur Kaminski, Director of the Poltransplant, personal information). In addition, 1 Ukrainian patient received a liver transplant, and 1 patient received a heart transplant. At our institution (National Institute Center of Child Health), we had 3 Ukrainian mothers donating a kidney to their children. All Ukrainian transplant recipients (transplanted in either Poland or Ukraine) are followed in the same manner in transplant outpatient clinics with laboratory assessment including calcineurin inhibitor, mammalian target of rapamycin levels, and physical examinations. Immunosuppressants and other medications are provided free of charge. Immunosuppressive therapy is reimbursed in Poland with a nominal price of <1 Euro per package (usually 30 pills). The support with immunosuppressants in Ukraine is variable. Challenges for patients with CKD, in particular on RRT linked to medical and logistical challenges in Ukraine, have been published recently.8 This report stressed that patients may experience limitations of dialysis or availability of immunosuppressive medications, increasing the risk of severe complications, including death. Overall, the unfortunate consequences of the COVID-19 pandemic with excess mortality rates9 made it possible to accommodate all refugees requiring dialysis, for both short- and long-term treatment. This approach is based on established policies that refugees are entitled to receive the same standard of care as Polish citizens. As stated by others before,8 we feel it is our moral duty to provide dialysis care to all refugees in need. Limited resources may be a concern moving forward, particularly when struggling with the consequences of a pandemic resulting in late referrals and lower numbers of organ transplantations. These data were presented in part at the Transplantation Congress in Buenos Aires, Argentina, in September 2022.

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