1 Cerrahpasa, Medical Faculty Istanbul, Turkey,
2 Istanbul Medical Faculty, Istanbul, Turkey,
3 Gent, Belgium,
4 Marmara University, Istanbul, Turkey,
5 Uluda University, Bursa, Turkey,
6 Göztepe Social Security Hospital, Istanbul, Turkey,
7 Kartal State Hospital, Istanbul and
8 Ankara Medical Faculty, Ankara, Turkey
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 1645 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 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.
Keywords: acute renal failure; crush injuries; morbidity; mortality; Marmara earthquake
Introduction
At 03:02 (local time) on August 17, 1999 Turkey suffered from the effects of a devastating earthquake, registering 7.4 on the Richter Scale. The epicentre was located in Gölcük, a town near Izmit City in the Kocaeli province at the eastern end of Marmara Sea. The earthquake, subsequently known as Marmara, caused severe damage and the collapse of buildings over a 300 km distance and covered a total area of 64365 km2 in 10 provinces of the most densely populated and heavily industrialized regions of north-western of Turkey (Bilecik, Bolu, Eskisehir, Istanbul, Kocaeli, Sakarya, Tekirda, Yalova, Zonguldak).
Of the 15.8 million inhabitants in the area, 80% were city-dwellers, and the casuality figures of 17 479 deaths and 43 953 injuries [1] with 24 000 hospitalizations [2], were not surprising since the quake occurred at a time when people were sleeping. Most of the deaths resulted from crush or suffocation in collapsed dwellings. The number of moderately damaged buildings was 77 200 [3], and the number of heavily damaged or completely collapsed buildings was
77 297 (Table 1
).
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The aim of this report was to provide an overview of the morbidity and mortality of all the documented patients with ARF as a result of crush injury following the Marmara earthquake. They were hospitalized in 35 different hospitals having dialysis units in Istanbul, Ankara, Bursa, Eskiehir, Izmir and Samsun.
Subjects and methods
Patient information and data were obtained through special questionnaires sent out to all hospitals with dialysis units known to have admitted earthquake victims with renal problems. These questionnaires were prepared and distributed by the Marmara Earthquake Task Force of the Turkish Society of Nephrology (TSN) working in close collaboration with the Renal Disaster Relief Task Force representatives of the International Society of Nephrology (ISN) who had arrived Turkey just after the disaster.
Responses to questionnaires from the TSN Task Force were completed by the end of October 1999 and throughout this period, close contact by fax, telephone, and/or e-mail was maintained with most of the 35 hospitals involved in this study.
Population
The exact total number of injuries that required hospitalization is not known. But of the 43 953 injured victims [1], it was estimated that at least about 24 000 required some short- or long-term hospital care and/or treatment [2]. A total of 639 patients (291 women and 348 men) were hospitalized for acute renal failure (ARF) as a result of earthquake-related crush injuries, and they constituted roughly 2.6% of the hospitalized earthquake victims. Patients dead on arrival, patients with inaccurate records, patients with prior chronic renal disease, and patients who did not meet the diagnostic criteria for both crush syndrome and ARF were excluded from the study.
Data collection
Patient census data, complaints, diagnoses, injury types, details on clinical course, surgical interventions, frequency, amount and duration of dialysis, blood pressure, presence of fever and relevant laboratory findings were retrospectively evaluated from five-page questionnaires. For practical purposes, patients with crush injuries (patients who were injured by collapsed material and manifested muscle swelling and/or neurological disturbances in the affected section of the body) [13] and without prior chronic kidney disease who presented with azotaemia (BUN 40 mg%) and/or increased creatinine levels (
2 mg%) with or without oliguria and hyperkalaemia were considered as ARF cases as result of crush injuries. These patients constitute the subject of this report.
Data analysis
All data were evaluated using a Microsoft Excel 97 spreadsheet and SPSS v. 8.0 statistical software. To avoid duplication in the census data for patients admitted to more than one hospital, we reported only from the hospital that discharged the patient. However, for medical information regarding admission, the records from both hospitals were equally considered.
Results
General features
Of the 639 patients admitted for ARF, 162 were not dialysed, 15 died before dialysis could be instituted, and 147 recovered without a need for dialysis. The remaining 477 patients (74.6%) received some form of dialytic therapy (Table 2). A total of 620 questionnaires revealed a mean age of 31.7±14.7 years (range 090), and 71% of the patients were young adults within the age of 1645 years. Age groups were as follows (in years): 015, 11.4%; 1630, 40.9%; 3145, 30.2%; 4660, 13.8%; 6175, 2.9%; 7690, 0.61%.
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Morbidity
Acute renal failure
Oliguria (53.2%), uraemia (94%), elevated creatinine levels (87%), hyperkalaemia (42%), hyperphosphataemia (63%), hypocalcaemia (83%), and high creatinine phosphokinase (CPK) levels (73%) were the most frequently encountered abnormalities related to the morbidity of ARF as a result of crush injury on admission. In the 340 patients with oliguria (400 ml/day) on admission, oliguria presented a mean duration of 11±7.7 days, indicating a benign course and quick recovery from the underlying ARF (Table 3
).
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Traumatologic events
These are summarized in Table 4.
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Medical problems
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Mortality
Overall causes of death are summarized in Figure 1. A total of 97 patients (15.2%) died (50 of 348 male patients and 47 of 291 females). Mortality was not different according to gender (P=0.53). In our ARF group, the percentage of older patients was strikingly small. Nevertheless, the age distribution of the on the scene fatalities remains unknown. The mortality rates of dialysed and non-dialysed patients were 17.2% (82 of 477) and 9.3% (15 of 162), respectively (P=0.015).
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Medical problems related to mortality
Univariate analysis revealed that traumatologic problems, sepsis (in 19% of patients), and problems such as high fever, hypotension, DIC, and thrombocytopenia (probably related to sepsis), all showed significant individual associations with mortality. The presence or development of ARDS and/or respiratory failure in 7.3% of patients, often in conjunction with sepsis, was also significantly associated with mortality (Table 7). However, multivariate analysis revealed that both DIC and ARDS, and/or respiratory failure, were frequently related to sepsis, and were the two major determinants of mortality (Table 8
).
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Trauma-related mortality
Mortality was significantly associated with thoracic and abdominal traumas, seen in 69 (10.8%) and 41 (6.4%) patients, respectively. It was also associated with amputations, performed in 95 (14.9%) of the patients with extremity traumas (Tables 6 and 7
). The significant impact of thoracic and abdominal traumas in trauma-related mortality also persisted in the multivariate analysis (Table 7
). Extremity traumas that did not require amputation and other traumatologic events such as head injuries, multiple injuries, and non-extremity fractures showed no significant association with mortality.
Similarly, despite high overall mean CPK values (Table 3) and rhabdomyolytic range (i.e.
1500 U/l) in 74% of patients, these levels were not associated with mortality and were similar in both the dead (23 748±45 672 U/l) and in surviving patients (24 043±44 790 U/l).
Discussion
There are only a limited number of reports on ARF cases as a result of crush injury following major earthquakes. After the Armenian earthquake of 1988, at least 26 000 deaths and some 385 cases of ARF secondary to crush syndrome were registered, but documented cases with hospital records and follow-up were limited [9,10]. Following the Iranian quake of 1990, which resulted in 13 888 deaths, 43 390 injuries, and 33 615 hospitalizations, 154 cases of ARF required dialysis support, but only 30 of these cases were reported in any detail [11]. In the Hanshin-Awaji or Kobe earthquake of 1995, there were 5500 dead, and 41 000 injured, and 372 hospitalizations with crush syndrome. 202 of the latter patients developed ARF, requiring dialysis in 123 (61%). These patients were described in a detailed report based on hospital records [8].
The Marmara earthquake resulted in 17 479 deaths and 43 953 injuries. A total of 639 patients were hospitalized with detailed documentation of ARF-related crush injury. This number exceeds similar cases previously reported in conjunction with any single earthquake [711].
Our 639 cases with ARF corresponded to roughly 2.7% of the 24 000 earthquake-related hospitalizations. Interestingly, the 202 ARF cases in the Hanshin-Awaji earthquake also accounted for 3.3% of the 6107 hospitalizations. In the Iranian earthquake, which primarily affected rural areas, Atef et al. [11] reported an ARF incidence of only 0.5%. This is in line with previous observations showing a higher frequency of crush syndrome following earthquakes involved collapse of multi-storey buildings compared with those characterized by collapse of one-storey adobe and wood-frame structures [11,12].
Obviously, our ARF incidence was also strongly related to intensity of the earthquake. In fact, 584 (91.4%) of our patients came from four towns that had an earthquake intensity of IXX on the MSK scale, and the death toll of 14 249 individuals (Table 1) in these four towns accounted for 81.4% of the total deaths despite their population of only 1 096 290 inhabitants, corresponding to only 13.5% of the total earthquake area population.
In the present series, the percentage of older patients was strikingly small. In fact, despite a population percentage of 8.4% in the Marmara Region for subjects >60 years, the same age group constituted only 3.5% of our patients [13]. Because the age distribution of the fatalities on the scene remains unknown, this small number may be related to previous observations that elderly people are more likely to sustain earthquake-related injury [14] but have a much higher on the spot fatality [15,16].
ARF resulting from rhabdomyolysis related to various causes had a reported mortality exceeding 40% [17]. Also, Atef et al. [11] reported a 40% mortality in 30 earthquake victims with ARF admitted to three teaching hospitals in Tehran [11]. In contrast, ARF mortality was 50 of 202 or 24.7% in the Hanshin-Awaji earthquake [8]. The overall mortality in our patients was 15.2%, a figure substantially lower than those cited above. It reached 17.1% in the dialysed patients but was 9.2% in patients not dialysed and suffering from a milder form of injury.
In the absence of abdominal or thoracic trauma or sepsis complicated by DIC or ARDS/respiratory failure, ARF per se did not appear to be a significant cause of death in our patients. Application of protective on the scene such as fluid administration, a reasonably short delay before hospitalization (a mean of 3.4 days following the earthquake), and the availability of equipment and staff to assure intensive and effective around the clock dialysis in almost all receiving hospitals seem to have contributed to this favourable result. In the 15 patients that died before dialysis could be started, factors directly associated with ARF, including hyperkalaemia and/or circulatory overload played a minor role in mortality whereas sepsis, DIC, and ARDS were more important (Table 7).
Thoracic and abdominal traumas were seen in 10.8 and 6.4% of our patients, respectively. Amongst crush syndrome patients of the Hanshin-Awaji earthquake, Oda et al. [8] reported trunk injuries in 8.6% and associated abdominal injuries in 4.3% of patients.
In our patients, extremity traumas that did not require amputation and traumatologic events, such as head injuries, multiple injuries, and non-extremity fractures, including cranial, pelvic, and vertebral fractures had no association with mortality. Conversely, abdominal traumas and amputations were each significantly associated with mortality (Table 6). The significant weights of thoracic and abdominal traumas on trauma-related mortality were also confirmed by multivariate analysis (Table 8
). Similarly, Oda et al. [8] reported a higher mortality with trunk involvement compared with crush injury to other anatomical sites following the Hanshin earthquake. In addition, injuries of the chest and abdomen constituted 42.4 and 21.2%, respectively, of fatalities that followed the Northridge earthquake [14].
Apart from ARF and traumatologic problems, our patients also had a wide spectrum of medical problems (vide supra). Of these, hypertension, congestive heart failure, pulmonary thromboembolism, gastrointestinal problems, and infection uncomplicated by sepsis had no significant association with mortality. In contrast, sepsis and other problems, such as high fever, hypotension, DIC, and thrombocytopenia, were each significantly associated with mortality on univariate analysis. The presence or development of ARDS/respiratory failure in 7.3% of patients, often in conjunction with sepsis, and perhaps related to dust inhalation in some cases [18], also showed a significant association with mortality (Table 7). On multivariate analysis, however, only DIC and ARDS/respiratory failure emerged as significant determinants of mortality (Table 8
). In fact, despite the availability of high quality intensive care in almost all instances, 5054% of patients with DIC and/or ARDS/respiratory failure could not be saved.
As expected [19,20], fasciotomy was a significant predisposing factor for development of sepsis in our patients (Table 5). However, it showed no significant association with mortality (Table 8
).
The proportion of patients with ARF requiring dialysis ranged from 20 to 60% [2125]. Despite major advances in dialysis and intensive care, the mortality rate among patients with severe ARF requiring dialysis has not decreased appreciably over the past 50 years. Mortality rates in previously reported ARF outcome data ranged from 7% among patients with prerenal azotaemia to >80% in the patients with post-operative ARF [26,27]. When ARF occurs in patients with multi-organ failure, especially with severe hypotension or ARDS, the mortality rate ranges from 50 to 80% [27,29], and with the advent of dialysis the most common causes of death are sepsis, cardiovascular and pulmonary dysfunction, and withdrawal of life-support measures [28,29].
In conclusion, severe disaster and major earthquake 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 readily available, crush injury-related ARF patients have a lowed mortality. Mortality, when it occurred, was mainly associated with thoracic and abdominal trauma and medical problems such as DIC and/or ARDS/respiratory failure, often in conjunction with sepsis.
Members of the Turkish Disaster Study Group
Uluda School of Medicine: Dr Kamil Dilek, Dr Osman Dönmez, Dr Mustafa Yurtkuran; Marmara School of Medicine: Dr Gülçin Kantarci, Dr Çetin Özenen; I·stanbul School of Medicine: Dr Rumeyza Kazancio
lu, Dr Aydin Türkmen; Göztepe Social Security Hospital: Dr Hasan Erbil, Dr Bilgin Çapano
lu; Kartal State Hospital: Dr Mehmet Çobano
lu; Dr Necmi Kurt; Cerrahpa
a School of Medicine: Dr Süheyla Apaydin, Dr Rezzan Ataman; Dr Mehmet Riza Altiparmak; Ankara School of Medicine: Dr Kenan Ate
, Dr Kenan Keven; GATA-Haydarpa
a Hospital: Dr Rifki Evrenkaya; Osman Gazi School of Medicine: Dr Haluk Kiper; GATA Ankara Hospital: Dr Müjdat Yenicesu; Ankara Numune Hospital: Dr Mansur Kayata
; Haydarpa
a Numune Hospital: Dr Funda Türkmen; Gazi School of Medicine: Dr
ükrü Sindel; Ba
kent School of Medicine: Dr Galip Güz; Bursa State Hospital: Dr Günay Okumu
; Ankara Social Security Etlik Hospital: Dr Murat Duranay; Bursa Social Security Hospital: Dr Celalettin Demircan; Hacettepe School of Medicine: Dr Yunus Erdem; Sisli Etfal Hospital: Dr Gülizar Manga; American Hospital: Dr Kemal Önen, Dr Moiz Bahar; Okmeydani Social Security Hospital: Dr Vedat Çelik; Florence Nightingale Hospital: Dr Erhan Kabata
; Police Hospital: Dr Betül Ö
ütmen; Cerrahpa
a School of Medicine Pediatric Nephrology Department: Dr Lale Sever; Teacher's Hospital: Dr Ali Saribiyik; Metropol Hospital: Dr Sezer Sa
lam; PTT Hospital: Dr Mustafa Çakçak; Samatya Social Security Hospital: Dr Mine Besler; I·stanbul School of Med Pediatric Nephrology Department: Dr Aydan
irin; Trakya School of Medicine: Dr Saniye
en; Hacettepe School of Medicine Pediatric Nephrology Department: Dr Ay
in Bakkalo
lu; 19 Mayis School of Medicine: Dr Nurol Arik; 9 Eylül School of Medicine: Dr Taner Çamsari; MSF Turkey: Dr Fikri Kutlay. The following friends spent at least 1 week for saving lives: Belgium: Dr Heidi Hoeben, Dr Bruno Van Vlem, Dr Wim Van Biesen; Germany: Dr Ralf Schindler; France: Dr Dilaver Erbilgin.
Notes
Correspondence and offprint requests to: Ekrem Erek, Cerrahpaa Tip Fakültesi, I·ç Hastaliklari Nefroloji Bilim Dali, Cerrahpa
a, Aksaray, 34300 Istanbul, Turkey. Email: e.erek{at}mail.com
References