An overview of morbidity and mortality in patients with acute renal failure due to crush syndrome: the Marmara earthquake experience

Abstract

Background: On August 17, 1999 a major earthquake hit the most densely populated area at the eastern end of the Marmara Sea in northwestern Turkey. The number of documented cases of acute renal failure (ARF) following this event exceeded all similar cases previously reported for any single earthquake. The aim of this report was to provide an overview of the morbidity and mortality of all documented patients with ARF, due to crush injury, that were treated in hospitals with dialysis units following the Marmara earthquake.

Methods: Special questionnaires were sent out to all hospitals with dialysis units known to have admitted earthquake victims with ARF and related crush injuries. Responses to questionnaires from the Turkish Society of Nephrology (TSN) Task Force were collected from 35 hospitals in October 1999. We retrospectively evaluated patients, clinic and laboratory findings, surgical interventions, and frequency and duration of dialysis. Patients who died before or on admission and those with prior chronic renal disease were excluded from the study.

Results: A total of 639 patients (291 female and 348 male) with ARF due to crush injury were hospitalized in 35 hospitals. The mean age was 31.6+/-14.7 years and 71.1% were young adults within the range of 16-45 years. 477 patients (74.6%) received one or more dialysis treatments, 162 patients were not dialysed, 15 patients died before dialysis could be instituted, and 147 patients recovered without dialysis treatment. 340 patients were oliguric on admission. The most important abnormalities related to ARF as a result of crush injury morbidity, were oliguria (53.2%), uraemia (94%), high creatinine levels (87%), hyperkalaemia (42%), hyperphosphataemia (63%), hypocalcaemia (83%), and high creatinine phosphokinase levels (73 %). 512 patients had a total of 790 extremity injuries. Eighty-three patients (12.9%) had fractures of the extremities and non-extremity fractures were observed in 59 (9.2%) patients. 323 fasciotomies were performed. Thoracic and abdominal trauma was observed in 110 patients (17.2%). Infection and sepsis were observed in 223 (34.9%) and 121 (18.9%) patients, respectively. Haematologic abnormalities were observed in 197 patients (33%) including 116 with Htc < or =30%. There were pulmonary problems in 96 patients (15%), cardiovascular problems in 198 patients (30.9%), gastrointestinal problems in 23 (3.16%), neurologic problems in 43 (6.7%), and psychiatric problems in 7 (1%) patients. Ninety-seven of the 639 patients with ARF as a result of crush injury died (15.2%), and mortality rates were 17.2 and 9.3% in dialysed and non-dialysed patients, respectively. Findings significantly associated with mortality were sepsis, thrombocytopenia, disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), and abdominal and thoracic traumas.

Conclusions: We conclude that in cases of severe disasters such as major earthquakes, patients should be rapidly transferred to undamaged peripheral general hospitals. When proper dialysis and intensive care facilities together with around the clock dedicated human effort are available, crush injury-related ARF patients have a lower mortality. Mortality, when it occurs, is mainly associated with thoracic and abdominal trauma and medical problems such as DIC and/or ARDS/respiratory failure, often in conjunction with sepsis.