Natural disasters impact millions worldwide each year, with earthquakes, hurricanes, and typhoons being the most destructive. One of the most severe complications of muscle damage is crush syndrome, which ranks as one of the leading causes of death following a major disaster. Leakage of harmful contents into the bloodstream usually results in Acute kidney injury (AKI), which occurs most often during mass casualty cases. While crush syndrome in adults is well-documented, data on children remain limited.
Immediately after the tragic 2023 KahramanmaraĹź earthquake in Turkey, pediatric intensive care physicians were interested in analyzing treatment outcomes in children who were treated with Kidney replacement therapy (KRT) for AKI resulting from crush syndrome.
This cohort study examined pediatric patients admitted to 20 hospitals across Turkey with earthquake-related crush syndrome and AKI requiring KRT. Ethical approval was obtained from the Istanbul Faculty of Medicine, with informed parental consent. Inclusion criteria included patients aged one month to 18 years diagnosed with both crush syndrome and AKI. The exclusion criteria included pre-existing chronic kidney disease, missing medical records, or failure to meet diagnostic criteria. Data was collected following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
Descriptive statistics included mean, standard deviation, median, interquartile range, and frequency values. The Kolmogorov-Smirnov test was used to determine data distribution. When independent variables were quantitative, the Mann-Whitney U test was used. In contrast, qualitative independent variables were analyzed using the χ² test, or the Fisher exact test was applied according to the situation. To study AKI severity and dialysis dependence at the time of discharge, the receiver operating characteristic curve was used, and the optimal cutoff points were determined with the Youden index. Logistic regression models were used to analyze significant associations. The value of P < 0.05 was considered for statistical significance. The data analysis was done between August and October 2024 using SPSS software version 27.0, IBM.
The study included 183 children with earthquake-related injuries (median age: 158 months, range: 108-192 months) with 49 males (54.4%). Out of them, 90 underwent KRT, and median and interquartile range (IQR) time spent under rubble was 25.7 hours (1-137 hours). On presentation, 51 patients (56.6%) were in stage 3 acute kidney injury; the median IQR of serum creatinine phosphokinase level was 15,555 (9,386-59,274) IU/L. The kidney disease improving global outcomes (KDIGO) stage at presentation had a significant correlation with serum creatinine phosphokinase levels (area under the curve: 0.750, 95% confidence interval (CI): 0.621-0.879; P < 0.001).
Among the patients treated with KRT, 33 (36.7%) received continuous venovenous hemodiafiltration, and 23 (25.6%) received intermittent hemodialysis (IHD). Only IHD showed statistically significant independent association with shorter PICU LOS (Odds ratio (OR): 6.87; 95% CI: 1.54-30.67; P = 0.01). The risk of dependency on dialysis at discharge was increased in the children who received delayed PICU transfer (β = 0.003; 95% CI: 0.001-0.005; P < 0.001) and the children with a high Pediatric Trauma Score (β = 0.022; 95% CI: 0.003-0.041; P = 0.02). In contrast, IHD was not a significant risk for dependency on dialysis at discharge. OR: 2.18; 95% CI: 0.53-8.98; P = 0.28. The overall mortality rate in the cohort was six patients (6.6%).
This study highlights the crucial role of early intervention following crush syndrome diagnosis in improving patients after natural disasters. Rapid transfer to pediatric intensive care units (PICU) and initiation of KRT soon before stabilization was essential for the patient’s recovery with preserved long-term kidney function. The research suggests developing specific protocols for treating disaster scenarios in children to prevent complications during such disasters.
Reference: Demirkol D, Besci T, Havan M, et al. Kidney replacement therapies and outcomes in children with crush syndrome–associated kidney injury. JAMA Netw Open. 2025;8(1):e2456793. doi:10.1001/jamanetworkopen.2024.56793.
