Survey of dialysis therapy during the Great East Japan Earthquake Disaster and recommendations for dialysis therapy preparation in case of future disasters
© Japanese Society for Dialysis Therapy 2016
Received: 19 June 2016
Accepted: 10 August 2016
Published: 25 August 2016
The survey of dialysis therapy during the Great East Japan Earthquake Disaster (GEJED) highlighted the vulnerability of chronic dialysis therapy and dialysis patients to disasters. To minimize negative effects on patients on chronic maintenance dialysis during large-scale disasters that may occur in the future, it is important to promote the self-help efforts of dialysis facilities and to develop mutual assistance systems within local communities. Each dialysis facility has to take comprehensive disaster managements, including vibration control of large machinery, the use of flexible tubes, securing patient beds, and un-securing stand-type bedside consoles. Local governments should plan in advance how to support chronic dialysis therapy in their areas and how to assign roles among themselves when dealing with a large number of patients with acute kidney injury during long-term disruption of lifelines including electricity, water supply, and fuel. Dialysis patients are likely to develop cardiovascular events in times of disaster because of physical and psychological stress. Dialysis patients should understand in advance the key points of self-care in times of disaster and the availability of dialysis therapy in remote locations. It is also important to provide appropriate antihypertensive treatment to patients.
The largest earthquake in recorded history in Japan with a magnitude (M) of 9.0, which was centered off the Pacific coast of Tohoku, hit the Tohoku region and all of eastern Japan from Hokkaido to the Kanto region at 14:46 on 11 March 2011. The subsequent enormous tsunami caused by the earthquake struck the coast of the Tohoku and Kanto regions, claiming a huge number of lives and inflicting tremendous damage on social infrastructures. In addition, accidents occurred at the Fukushima Daiichi Nuclear Power Station of Tokyo Electric Power Company. The Great East Japan Earthquake Disaster (GEJED) caused unprecedentedly serious and complex damage, from which the affected areas are still recovering.
Dialysis therapy, especially hemodialysis, is considered vulnerable to large-scale disasters because it uses approximately 250 L of water in one session of treatment, it cannot be performed without electricity, and it requires the smooth distribution of products such as dialyzers, blood circuits, and concentrates of dialysis fluid. There are two issues regarding dialysis therapy in times of a large-scale disaster: how to treat the acute kidney failure (AKI) due to rhabdomyolysis, which is caused by multiple injuries, and how to continue chronic maintenance dialysis. The incidents of AKI caused by multiple injuries were low in GEJED because 92.5 % of the victims died from drowning in the huge tsunami . The serious problem highlighted by this disaster was the difficulty in continuing maintenance dialysis due to the inundation of dialysis facilities by the tsunami, the long-term disruption of lifelines including electricity and water supplies over a wide area, and the disruption of product distribution.
Contents of report on survey of dialysis therapy during GEJE
I. List of recommendations for dialysis during disasters
Recommendation 1: Disaster countermeasures for dialysis facilities, the securing of lifelines, and a support system for supplying resources
Recommendation 2: Future disaster countermeasures based on the experiences in the affected facilities
Recommendation 3: Transfer of dialysis patients during disasters and dialysis therapy at alternative facilities
Recommendation 4: Care of dialysis patients during disasters
Recommendation 5: Support of human and material resources during disasters
Recommendation 6: Tokyo Inland Earthquake
Recommendation 7: Formation of collaborative systems among local dialysis facilities and governments, regular communications, and patient education
II. General: Large-scale disasters and dialysis therapy
Section 1: Outline of Great East Japan Earthquake Disaster
Section 2: Large-scale disasters and dialysis therapy
Section 3: Survey of dialysis therapy during the Great East Japan Earthquake Disaster
III. Each section: Results of survey of dialysis therapy during the Great East Japan Earthquake Disaster and recommendations for dialysis during disasters
Section 1: Current status of damage to dialysis therapy caused by the disaster-Analysis based on the annual JSDT Renal Registry
Section 2: Reports from affected areas
Section 3: Transfer of patients and dialysis therapy at alternative facilities
Section 4: Disaster-related patho-physiology in dialysis patients
Section 5: Support for affected facilities
Section 6: Preparedness for Tokyo Inland Earthquake
Section 7: Formation of local disaster response network, communication methods, and patient education
Currently, while the use of dialysis therapy is rapidly expanding mainly in developing countries, large-scale disasters such as earthquakes, floods, and droughts are occurring around the world. Providing dialysis therapy in times of large-scale disasters is now a global concern. We have realized through GEJED that it is our important responsibility to share the experiences with the world and to make recommendations for the continued provision of dialysis therapy in times of disaster.
Overview of damages from GEJED
Overview of the earthquake off the Pacific Coast of Tohoku
The Earthquake off the Pacific Coast of Tohoku occurred around the Japan Trench, which is the boundary of the North American plate and the Pacific plate that is sliding underneath the North American plate. This earthquake was of the “consolidated type,” namely, the earthquakes caused by three fault ruptures off the coast of Miyagi Prefecture, further off the coast, and in the adjacent sea of the northern area of Ibaraki Prefecture, were linked to each other. As a result, the ruptured part of the fault extended approximately 400 km in the north-south direction and 200 km in the west-east direction, generating a huge tsunami that hit a wide area from Hokkaido to Chiba Prefecture. The recorded height of the tsunami was more than 10 m along the Pacific coast of Aomori to Chiba Prefectures, 6–8 m along the Pacific coast of Hokkaido, 2–3 m along the Pacific coast of Tokai region, the Kii Peninsula, and Shikoku, and 1–2 m along the Pacific coast of Kyushu (Fig. 1). The inundation height, which was related to facility damage, increased southward from the central part of Aomori Prefecture, exceeding 10 m in the northern area of Iwate Prefecture, and reaching around 10–15 m along the Sanriku Coast including the Oshika Peninsula. The maximum inundation height along Sendai Bay was estimated to be 8–9 m. The maximum run-up height was 40.1 m which was recorded in Ofunato City, Iwate Prefecture. The tsunami destroyed breakwaters, devastated towns, ran up rivers, and even caused damage to settlements 6 km inland. The area affected by the inundation due to the tsunami and ground subsidence was 561 km2 and extended from Aomori to Chiba Prefectures.
Overview of damage
Damage to human life
Comparison of the Great East Japan Earthquake Disaster (GEJED) and the Great Hanshin-Awaji Earthquake Disaster (GHAED)
Damage to residential buildings
Damage to nonresidential buildings
Damage to roads
Damage to bridges
Period of traffic restrictions
1 year and 7 months
Approx. 0.045 million households
Approx. 1.3 million households
Gas supply interruptions
Approx. 0.42 million households
Approx. 2.6 million households
Approx. 8.44 million households
Approx. 2.6 million households
Approx. 1.9 million lines (fixed line)
More than 0.3 million lines
Disruption of lifelines
According to the government report published on 27 November 2012, the overview of the disruption of lifelines in GEJED was as follows; water supplies were disrupted for approximately 45,000 households; gas supply interruption, approximately 420,000 households; and power outages, approximately 8,440,000 households. Power outages affected significantly larger areas in GEJED than in GHAED (Table 2). Long-term interruption of the power supply occurred in a broad area particularly because of the accidents at the Fukushima Daiichi Nuclear Power Station of Tokyo Electric Power Company and the damage to thermal power stations. As a result, rolling blackouts were implemented across the country and the continuation of daily dialysis therapy was severely interrupted even in areas not directly hit by the earthquake.
GEJED caused massive damage to information and telecommunication infrastructures, including the breakage of transmission lines due to the earthquake and subsequent tsunami, the dysfunction of telecommunication buildings due to large-scale power outages, and the damage to cellular base stations. Approximately 1.9 million lines of four telecommunication providers and a maximum of 29,000 cellular and PHS base stations of five mobile telecommunication providers were out of service at that time. Telecommunications companies imposed communication restrictions in the early stages of the disaster, which largely interrupted information gathering and transmission as well as the confirmation of the safety of victims in the affected areas. Some social networking services on the Internet were effective under these circumstances and attracted attention as new ways to collect information and communicate in the affected areas. In addition, free services on public pay phones, specially installed public pay phones, emergency message services, and other measures of telecommunication were made available at that time. The communication, which failed because of the damage to information and telecommunication infrastructure, was recovered by the end of April 2011 in most areas.
Accidents at the Fukushima Daiichi Nuclear Power Station of Tokyo Electric Power Company
The damage caused by GEJED became severe and complicated because of the accidents at Fukushima Daiichi Nuclear Power Station of Tokyo Electric Power Company that followed the Earthquake off the Pacific Coast of Tohoku. The nuclear reactors operating at Daiichi and Daini Nuclear Power Stations shut down automatically immediately after the earthquake. After that, however, all AC power in these nuclear power stations was lost when the facilities were hit by the tsunami, making it impossible to cool their reactor cores. A nuclear emergency was declared at the Fukushima Daiichi Nuclear Power Station at 19:03 on March 11 and at the Fukushima Daini Nuclear Power Station at 7:45 on March 12. Efforts were made to prevent hydrogen explosions by venting (the release of steam out of a nuclear reactor containment to lower the pressure inside) and by pouring water into the nuclear reactor. However, hydrogen explosions occurred in Unit 1 at 15:36 on March 12, in Unit 3 on March 14, and in Unit 2 on March 15, resulting in the release of large amounts of radioactive materials. These accidents were reported to the International Atomic Energy Agency (IAEA) as level 7, the worst on the nuclear accident scale, on April 12.
At 21:23 on March 11, the Prime Minister ordered all residents within a 3-km radius of the Fukushima Daiichi Nuclear Power Station to evacuate and also all residents within a 3–10-km radius to stay inside their houses. Afterward, the evacuation area was expanded to a 20-km radius and the “stay in-house area” to a 20–30-km radius by March 15. Because of these evacuation orders for a broad area and the rumors concerning radioactive contamination, it became impossible to continue chronic maintenance dialysis therapy in that area and a number of dialysis patients needed to be transferred to other areas. On March 16, the US Government ordered all Americans in Japan within an 80-km radius of Fukushima to evacuate according to the advisory from IAEA. It was later pointed out that local residents were exposed to radioactive contamination because the results of the System for Prediction of Environmental Emergency Dose Information (SPEEDI) were not disclosed immediately after the accidents. Whether the evacuation area set by the Japanese government was appropriate or not has been examined . If the evacuation area had been set at an 80-km radius according to the IAEA, it would have included not only the cities of Koriyama and Fukushima but also Hitachi City in Ibaraki Prefecture all of which have many dialysis patients. It is beyond our imagination how many dialysis patients would have needed to be transferred and what kind of measures would have been required.
Disaster planning before GEJED
Disaster information network of the JADP
According to the cabinet office, Japan has experienced 20.6 % of earthquakes of M6 or higher, has 7.0 % of the number of active volcanos, and has sustained 18.3 % of the damage from disasters all over the world, although its total land area is only 0.25 % of the total world land area. Japan is one of the most disaster-prone countries in the world . Through its experience in a number of large-scale disasters, chronic dialysis therapy has become recognized as vulnerable to disasters, and various countermeasures with regard to this therapy have been established. As a result, the disaster information network on dialysis therapy correctly grasped the extent of damage and immediately established a dialysis support system during GEJED. This network was developed mainly by JADP after GHAED in 1995. Not only dialysis facilities throughout the country but also the disaster management department of the national and local governments participate this network, which is very effective for sharing real-time information in times of disaster.
JADP was established from the association of municipal societies of dialysis physicians in 1985. Since then, it has focused on preparation for disasters as one of its primary activities. In November 1987, the association launched an emergency dialysis therapy system for disasters, which is a system of registering data on dialysis facilities and patients with the aim of providing support in times of large-scale disaster and promoting research studies in ordinary times. In 1995, 1243 facilities (43.4 % of the facilities in the country) and 48,389 patients (31.3 % of the patients in the country) were registered in the system. However, this system did not work as expected in GHAED in 1995 because of the unexpectedly large extent of damage, and a large number of patients experienced difficulty in receiving dialysis therapy. From the experience in GHAED, JADP specified “the secure provision of dialysis therapy to patients undergoing maintenance dialysis and patients with AKI caused by crush syndrome in times of disaster as the primary purpose” of the preparation for disasters. The core activity of JADP focused on the establishment of a disaster management plan by the participating facilities and, for that purpose, the establishment of branch offices of JADP in each prefecture. Since 1999, the Internet-based information system for disasters, which had already been operating in Chiba Prefecture, has developed into a nationwide system. An information transmission drill has been performed once a year since 2000 up to the present.
The disaster information network of JADP consists of two information-sharing tools utilizing the Internet: a web-based disaster information network created for rapidly sharing precise information among affected areas, support areas, and governments in times of disaster (http://www.saigai-touseki.net/) and a crisis-management mailing list that was created as a nationwide information-sharing tool in 2003. This disaster information network functioned well during GEJED, enabling the establishment of a dialysis support system around an affected area or in a broader area as described later in their document. As a result, dialysis support was provided across the country to more than 10,000 patients during GEJED.
Approach of facilities to providing dialysis therapy during disasters
Since GHAED in 1995, increasing attention has been paid to how to provide dialysis therapy in the event of earthquakes and how to prepare for earthquakes in dialysis rooms. Akatsuka , in collaboration with JADP, summarized the damage to dialysis rooms caused by the Niigata Chuetsu-oki Earthquake by referring to his experiences in the area in Hokkaido frequently hit by earthquakes, and he has emphasized the significance of preparing beforehand for earthquakes in dialysis rooms. On the basis of past experiences, it was reported that the direct damage to dialysis rooms was prevented in earthquakes of intensity 5 and that maintenance dialysis was performed even in earthquakes of intensity 6+ . GEJED occurred amid the growing recognition of the significance of preparation for earthquakes in dialysis rooms. As previously mentioned, this was the third earthquake reaching the maximum intensity 7 following GHAED in 1995 and Niigata Chuetsu-oki Earthquake in 2004. The Southern Hyogo Prefecture Earthquake occurred in the early morning on a Tuesday when dialysis therapy was not performed in dialysis facilities. In the Niigata Chuetsu-oki Earthquake, there were no dialysis facilities in the area where the maximum intensity 7 was recorded. GEJED, however, occurred during the midday hours of Friday when dialysis therapy was being performed in dialysis facilities. There were dialysis facilities in the area where intensity 7 was recorded. This was a historical earthquake for dialysis therapy because it was the first time that an earthquake of intensity 7 occurred during the hours when the therapy was being performed. It was a good opportunity to see if the disaster management measures that had been implemented at dialysis facilities were effective. The various experiences obtained from this disaster will provide us with important knowledge about the preparation for large earthquakes that may occur in the future.
Results of survey of dialysis therapy during GEJED
Survey of dialysis therapy during GEJED
Items included in survey of dialysis therapy during GEJED
1. Seismic intensity at the facility site
2. Structure of buildings where dialysis equipment is located
3. Completion date of buildings where dialysis equipment is located
4. Seismic resistance of buildings where dialysis equipment is located
Interruption of dialysis services
5. Experience of the interruption of dialysis services due to the disaster
6. Length of time taken to resume dialysis services
7. Reasons for the interruption of dialysis services
Patient transfer and schedule adjustment
8. Requests for dialysis support to other hospitals
9. Acceptance of dialysis patients from other hospitals
10. Number of dialysis patients accepted
11. Schedule adjustment due to the acceptance of patients
12. Schedule adjustment due to the disaster
Disaster countermeasures at the facility (at the time of disaster/at the end of 2011)
13. Presence of private power generation systems that can be used for dialysis theraphy and their installation sites
14. Presence of water tanks (well water) for emergency use and their sizes
15. Earthquake-proof measures for RO systems and dialysis fluid delivery systems
16. Piping materials used for dialysis fluid delivery systems
17. Earthquake-proof measures for bedside consoles
18. Locking of bed casters
19. Means of information gathering and communication in times of disaster
20. Preparation of emergency release
21. Provision of information to patients receiving dialysis services under normal conditions
Damage to dialysis facilities and disaster management measures taken at facilities
Un-lock the casters of floor-type dialysis monitors.
Lock the casters of dialysis beds.
Fasten dialysis fluid delivery systems and reverse osmosis (RO) systems to the floor with anchor bolts or place those devices on a base isolation stand.
Use flexible tubes for the connection of dialysis fluid delivery systems and RO systems to the wall of a machine room.
Percentage of facilities that implemented four measures at the time of disaster
① Not locking dialysis monitors
② Locking dialysis beds
③ Fastening dialysis fluid delivery systems and RO system
④ Using flexible tubes
Percentage of facilities that implemented four measures and percentage of facilities where equipment was damaged in three prefectures
Fastening dialysis fluid delivery systems and RO systems to floor (%)
Using flexible tubes for connection (%)
Dialysis monitors (%)
Dialysis beds (%)
Equipment damage (%)
Impact of private electric generators and water tanks
Private electric generators, which are generally thought to be useful for providing dialysis services in the event of power outages, were installed in 55.4 % of the 3559 facilities that responded to the relevant question. There was a substantial difference among prefectures in the installation of private electric generators. The percentage of facilities having private electric generators was low in the prefectures with large, densely populated cities; the lowest was in Tokyo (37.3 %) followed by Chiba (38.2 %) and Osaka (39.4 %). The status of the installation of water tanks was almost the same as that of private electric generators. However, among the 315 facilities that experienced the interruption of dialysis services, 67.7 % of the 124 facilities that had private electric generators indicated “power outage” as the reason for the interruption. The additional survey revealed these reasons why this was the case: they could not generate a sufficient amount of power needed for maintenance dialysis; they could not obtain oil for the generators; or the electric generators did not work because of a lack of regular maintenance. Similarly, among the 315 facilities that experienced interruptions in dialysis service, 45.5 % of the 110 facilities that had water tanks indicated “water outage” as the reason for the interruption. These outages occurred because of power outages, water supply shortages, and damage to water storage equipment. As already mentioned, even when dialysis facilities install private electric generators and water tanks, there is a possibility that such equipment will not work depending on the scale and characteristics of disasters. Such equipment cannot provide absolute security. It is important to develop a mutual assistance system to meet the needs in each area.
Patient transfer for maintenance dialysis in alternative place
Number of facilities that accepted more than 100 dialysis patients and number of patients accepted in each prefecture
Along with the acceptance of patients, 257 facilities (25.9 % of the facilities that accepted the patients) changed their dialysis schedule, most of them for less than a month. However, the dialysis schedule was adjusted because of rolling blackouts in 736 facilities, which was far more than the number of facilities that accepted the patients. The schedule needed to be adjusted because of rolling blackouts in the Tohoku, Hokkaido, Kanto, Koshinetsu, and Chubu regions but not in the Kinki, Shikoku, and Kyushu regions. In times of large-scale disaster, rolling blackouts will become a problem not only in affected areas but also across the country.
PD therapy in times of disaster
While hemodialysis is an in-house treatment largely relying on infrastructure for electricity, water supply, and smooth distribution of products among other needs, peritoneal dialysis (PD) is a home-based treatment relying less on infrastructure. As described previously, in GEJED, the continuation of hemodialysis became impossible because of the damage to the infrastructure in wide areas caused by the earthquake and subsequent tsunami. More than 10,000 patients across the country needed dialysis support, and it was necessary to transfer a large number of patients from Miyagi and Fukushima Prefectures. The status of PD patients in GEJED has not been investigated in detail probably because the incidence of severe problems encountered in continuing PD therapy was significantly lower than that for hemodialysis. The following describes the status of PD patients in Iwate, Miyagi, and Fukushima Prefectures that were severely damaged by the disaster.
There were 144 PD patients in Iwate Prefecture when the disaster occurred. Of them, one patient who lived in the coastal area died in the tsunami, 12 patients were hospitalized because of power outages, and 5 patients needed hospital treatment for medical conditions such as peritonitis. There were 36 patients living in the coastal area severely damaged by the tsunami. Of them, 13 patients needed to move to other areas to receive dialysis because their houses were washed away or inundated or because of the long-term power outage. Twenty-two patients could stay in their homes and continue dialysis. Because the inland area of Iwate Prefecture was less devastated and the prefectural hospitals were well prepared for disasters, the facilities in the inland area could provide early support to the facilities in the coastal area. The problem that arose in all areas was how to secure a stable power supply for connection devices and automated PD (APD) machines during the power outage. This problem was overcome by using the manual exchange technique called continuous ambulatory PD (CAPD) or by recharging the devices at fire departments. After the power supply was restored, PD was continued stably.
There were 63 PD patients in Miyagi Prefecture, and one of them who lived in the coastal area died in the tsunami. There were 20 PD outpatients in the Japan Community Health Care Organization (JCOH) of Sendai Hospital, located at the central inland area of the prefecture, and they had fewer problems than the hemodialysis patients who faced many serious problems. Of the 20 patients, 12 were CAPD patients. They had a sufficient stock of dialysis fluids in their homes and therefore continued the home-based treatment. Eight were APD patients, and five of them could not continue APD because of power outages. They continued dialysis by changing from APD to CAPD and soon went back to APD after the power supply was restored. Two patients were hospitalized, one because the patient’s house was damaged, and the other because the patient developed peritonitis after changing the dialysis mode. The hospital provided dialysis support to hemodialysis patients from 36 facilities beginning the day after the occurrence of the disaster, but there were no PD patients from other facilities who needed dialysis support. There were 17 PD patients in Senseki Hospital located at the coastal area of the prefecture, and one of them died in the tsunami. Because the area was severely damaged by the tsunami, these patients faced many problems such as the washing away of houses and dialysis equipment, long-term power outages, and difficulties in securing a place for the exchange of dialysis fluids. The hospital also had a small stock of dialysis fluids, so it offered a limited range of dialysis services while waiting for the emergency delivery of dialysis fluids.
There were 152 PD patients in Fukushima Prefecture. The hospital staff and the PD companies tried to confirm the safety of patients and could contact all the patients except for one missing patient within a week of the disaster. Some patients could not receive PD therapy at their hospitals, but they received PD therapy at the back-up hospitals. The provision of dialysis support was not a burden to those hospitals because the frequency of hospital visits was usually once every 2 to 4 weeks for PD patients.
The reports from the affected areas showed that, as we expected, the problems affecting PD patients were much fewer than those affecting hemodialysis patients. The reasons for this may be that PD relies less on social infrastructure for electricity and water supply and that there is no problem about the transportation to dialysis facilities because PD is a home-based treatment with a certain amount of dialysis fluids stored at patients’ homes. During GEJED, the transportation available to hemodialysis patients was very limited because of the damage to roads across wide areas caused by the tsunami or the lack of gasoline due to the interruption of product distribution. The residential area of PD patients is larger than that of hemodialysis patients, and medical institutes may have difficulties in confirming the safety of their patients. However, the PD companies regularly contact patients requiring their delivery of PD fluid and those companies can help confirm the safety of the patients. Although electricity is needed for bag-exchange devices and APD, PD can be continued during the acute phase after a disaster by changing from APD to CAPD, as mentioned in the report from the affected areas. We have concluded that PD was far more resilient to disasters than hemodialysis, as shown by the experiences in GEJED.
Clinical conditions of dialysis patients in times of disaster
As described previously, there are two problems in dialysis therapy during large-scale disasters: the provision of dialysis as an emergency treatment and the maintenance of chronic dialysis. These two aspects are closely related because, when a large number of patients develop AKI due to crush syndrome and require dialysis therapy, it affects the continuation of chronic maintenance dialysis. When the patients undergoing maintenance dialysis develop crush syndrome, their clinical condition is considered urgent or life-threatening because of the effects of hyperkalemia and acidosis due to muscle degeneration. The immediate transfer to emergency care hospitals is crucial for their survival.
The death toll for GEJED was 19,335 (official announcement of the Fire and Disaster Management Agency on 9 September 2015 ), which was nearly threefold that for GHAED. In GEJED, the causes of death were 92.5 % of the victims drowning in tsunami, 4.4 % crushing and fatal injuries, 1.1 % fire, and 2 % unknown . On the other hand, in GHAED, 85.7 % of the victims died as a direct result of the earthquake. Among them, 72.6 % died from suffocation and crushing, 7.8 % died from traumatic shock, and 7.4 % died from fire. In GEJED, most of the victims died from drowning and few patients developed acute renal disorder. Hence, medical institutes focused on continuing maintenance dialysis.
In times of large-scale disaster, various cardiovascular events are induced by increased sympathetic nervous system tone due to physical and psychological stress and thrombotic tendency due to decreased daily activity. Dialysis patients often have to eat the same meals as other evacuees at evacuation centers. Therefore, they face the risk of various health problems, including congestive heart failure due to excess salt intake and hyperkalemia, or they may develop dehydration due to the excessive care about hyperkalemia and excess salt intake .
There have been reports from the affected areas about the hemodynamic changes of dialysis patients in GEJED. Some reported that there was no change in blood pressure, while many reported that a temporary increase in blood pressure was observed after the disaster. The increase in blood pressure was not caused by an increase in extracellular body fluid but may be caused by stress. The JCHO Sendai hospital in Miyagi Prefecture reported that 67 patients were hospitalized because of congestive heart failure during the 3 months following the disaster, which was more than twice that during the same period of the preceding year (29 patients).
Number of deaths from specific causes per 1000 dialysis patients in 2011 compared with previous year
Total deaths (%)
Heart failure (%)
Cerebral vascular (%)
Three prefectures in Tohoku
Four prefectures in Shikoku
Number of deaths from specific causes per 100,000 general population in 2011 compared with previous year
Total deaths (%)
Heart disease (%)
Cerebral vascular (%)
Three prefectures in Tohoku
Four prefectures in Shikoku
As described, it is acknowledged that both dialysis therapy and chronic dialysis patients are vulnerable in disasters. Sakai  reported that even dialysis patients who appeared in good condition in the aftermath of t GHAED died suddenly, due to brain hemorrhage, gastrointestinal bleeding, or unknown causes, 6 months or later after the earthquake, indicating how much stress the patients experience in the time of large-scale disasters. Kario also reported that patients were prone to develop cardiovascular events in times of disaster, but that patients who were taking α- or β-blockers and diabetic patients with autonomic neuropathy showed less increase in blood pressure . Elevated blood pressure in facilities and home was also reported in GEJED [13, 14]. Tanaka et al. suggested the advantage of RAS inhibitors for home blood pressure stability under a disaster .
On the basis of these survey results and past reports, the WG proposed that chronic dialysis patients should have adequate sleep and keep their body and mind at rest, should measure their blood pressure and pulse and receive appropriate antihypertensive treatment including sympathetic blockers, and should avoid over-hydration and dehydration in times of disaster.
The survey of dialysis therapy during GEJED showed that, as previously suggested, both dialysis therapy and patients undergoing maintenance dialysis are vulnerable in disasters. From the viewpoint of the maintenance of chronic dialysis, dialysis facilities should take the four disaster management measures proposed by Akatsuka to prevent the interruption of dialysis services due to facility damage. However, the effectiveness of self-help efforts is limited in certain large-scale disasters. It is, therefore, necessary to establish mutual assistance systems for supporting dialysis therapy in local areas through the provision of electricity, water, and fuels such as gasoline and oil. When a disaster of a much larger scale occurs, it is impossible to support dialysis patients by self-help efforts and mutual assistance systems alone. Public help is required in such a disaster.
Dialysis patients are likely to develop cardiovascular events because of physical and psychological stress due to a disaster. They should keep their body and mind at rest and receive an appropriate antihypertensive treatment to reduce the sympathetic nervous system tone. They should also understand in advance the precautions to be taken for daily self-care, communication method in times of disaster, and the availability of dialysis therapy in remote locations.
In the event of a huge disaster that may occur in the future, the measures required to provide dialysis therapy smoothly will be different from those required in GEJED depending on the type of disaster, the extent of damage, the number of dialysis patients living in an affected area, and the occurrence of acute traumatic AKI. However, it is possible to minimize the damage to dialysis therapy facilities caused by disasters if each dialysis facility and each local community now take as many of the measures as possible that are proposed in this report.
Acute kidney failure
Automated peritoneal dialysis
Continuous ambulatory peritoneal dialysis
The Great East Japan Earthquake Disaster
The Great Hanshin-Awaji Earthquake Disaster
The International Atomic Energy Agency
Japan Association for Clinical Engineers
Japanese Association of Dialysis Physicians
Japanese Society for Dialysis Therapy
Japanese Society of Nephrology
The System for Prediction of Environmental Emergency Dose Information
We greatly thank all dialysis facilities members of JSDT who answered the questions in 2011 JSDT survey for GEJED and the subsequent questions in 2013. We also greatly thank for Japanese Association of Dialysis Physicians (JADP), Japanese Society of Nephrology (JSN), Japan Association for Clinical Engineers (JACE), Japan Academy of Nephrology Nursing (JANN), Japanese Society for Technology of Blood Purification (JSTB), and Medical Technology Association of Japan (MTJAPAN) for composing “Report of Survey of Dialysis Therapy during the Great East Japan Earthquake Disaster: Recommendations for Dialysis Therapy Preparation in Case of Future Disasters” published in 2013 by JSDT.
All efforts and costs for the survey for GEJED and making the report was given by JSDT.
Availability of data and materials
The data and recommendations in the current manuscript are important information for all dialysis facilities, medical staffs, officers working in crisis management and dialysis patients, so all of them are freely available with stating “data from JSDT”.
IM wrote the part I and II-6 in the original report and summarized the original huge data from JSDT and made them into the current manuscript. TA wrote the part II-2 in the original report and had a responsibility in editing the original report. TY wrote the part II-1 in the original report and had a responsibility in editing the original report. YT organized the final structure of the JSDT survey for GEJED. RA approved the final proposals for dialysis in a disaster as an executive officer of crisis management in JSDT. TA was an ex-president of JSDT in 2011, who directed the JSDT survey for GEJED. JM was an ex-president of JSDT after TA and directed the process of summarize the JSDT survey for GEJED. KN is the president of JSDT and gave the final approval for the entire manuscript. All authors read and approve the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
The JSDT registry was approved by the ethical committee of JSDT.
The original data had been totally anonymized so there are no risks for deteriorating the privacy of the dialysis facilities and the patients.
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