Introduction
Maintaining dialysis care following large-scale disasters is one of the most challenging issues for health care systems in medically underserved areas. Dialysis patients require regular, specialized treatment, making them particularly vulnerable when medical infrastructure is destroyed or long-term evacuation is necessary. Moreover, post-disaster medical reconstruction often spans many years, potentially leaving dialysis patients facing prolonged difficulties in accessing care, which has been reported to result in physical and mental damage, as well as a decline in quality of life (QOL).Reference Ishiki, Okinaga and Tomita1–Reference Hashimoto, Nagai and Fukuma3
Kidney transplantation is widely implemented as a treatment for end-stage renal disease. While it requires specialized surgical facilities and long-term immunosuppressive therapy, transplantation may potentially reduce the overall burden on patients compared to maintaining long-term dialysis treatment. Nevertheless, there is a paucity of information regarding the implementation and effectiveness of kidney transplantation as a long-term mitigation strategy for addressing the impact of disasters on patients requiring chronic dialysis treatment. Despite its potential benefits in reducing health care system dependencies during disasters, neither the feasibility nor the outcomes of such an approach have been adequately studied or documented in disaster preparedness contexts.
The Great East Japan Earthquake and subsequent tsunami and Fukushima Daiichi Nuclear Power Plant accident on March 11, 2011, present a stark and unique context for examining this issue. The area along the Fukushima Prefecture coastline, where the Fukushima Daiichi Nuclear Power Plant is located, has historically faced a shortage of health care workers and medical facilities due to its geographical characteristics. Dialysis facilities were particularly insufficient even before the disaster, with some patients forced to seek treatment outside their local area. Amidst these pre-existing challenges, the dialysis health care system was further severely impacted by the destruction of medical facilities, the outflow of health care workers, and long-term evacuation orders caused by the earthquake.Reference Nishikawa, Ozawa and Tsubokura4 Subsequently, approximately 600 hemodialysis patients were forced to evacuate their hometowns and continued their treatments at alternative facilities located near their temporary housing.Reference Kazama and Narita5 While 1 core hospital in Minamisoma City initiated new maintenance dialysis services after the disaster, its capacity remained limited and insufficient to meet local needs.
This study presents a successful case of kidney transplantation from the Fukushima coastal area, demonstrating how transplantation can serve as an effective solution for addressing dialysis access challenges in disaster-affected regions. The case demonstrates how early consideration of transplantation can improve patient outcomes in medically underserved areas, providing an effective solution where maintaining post-disaster dialysis infrastructure remains challenging even 13 years later.
This study was performed in accordance with the guidelines of the Declaration of Helsinki. This patient provided written informed consent before the study.
Case Report
A woman in her 30s with diabetic nephropathy was identified early as an excellent candidate for kidney transplantation. During her initial evaluation, our transplant team recognized the opportunity for living donor transplantation, though treatment for diabetic retinopathy was prioritized in the immediate term. As her renal function declined, the patient was referred to our hospital, located 80 kilometers from her home in Minamisoma City, where health care access remained limited 13 years after the earthquake. While one core hospital in Minamisoma City had initiated maintenance dialysis services post-disaster, its capacity could not meet the growing needs of the local community.
In February of Year X-2, she began hemodialysis at our hospital while simultaneously pursuing evaluation for living donor transplantation. The patient required nearly 4 hours for a round-trip commute by car on dialysis days. The thrice-weekly dialysis schedule required significant travel time, with her father providing transportation due to her visual impairment from diabetic retinopathy. When combined with the 4-hour dialysis session itself, the treatment consumed the majority of the day. In addition to this significant time burden, the patient traveled approximately 80 kilometers one way via expressway, which imposed additional economic burdens, including highway tolls and fuel expenses. Despite the substantial burden, this patient did not consider relocation, as they were expecting that dialysis would eventually become available at a local hospital. This patient might not have considered kidney transplantation had maintenance dialysis been available locally prior to surgery. However, due to the continued unavailability of dialysis slots at nearby medical facilities even after the initiation of dialysis, the patient subsequently developed a strong interest in pursuing transplantation. Our transplant team worked closely with the patient and her father, who was identified as a suitable living donor, to prepare for transplantation.
In February of Year X, she successfully underwent living donor kidney transplantation with her father as the donor. Tacrolimus, mycophenolate mofetil, methylprednisolone, and basiliximab were introduced as initial immunosuppressants. The surgery and immediate post-operative course progressed smoothly, allowing her discharge just 2 weeks after the procedure. The serum creatinine level ranged between 7 mg/dL and 10 mg/dL before surgery, and gradually decreased postoperatively, reaching 1.62 mg/dL at the time of discharge. The transition to transplantation proved highly beneficial—her monthly follow-up visits replaced the previous thrice-weekly dialysis schedule, significantly reducing the transportation burden on her family. The successful transplant outcome has enabled her to pursue her professional goals with greater independence, demonstrating the transformative potential of early transplantation for suitable candidates in medically underserved areas.
Currently, her transplanted kidney function remains excellent under our ongoing care through monthly transplant clinic visits. The patient was maintained on a regimen of immunosuppressive therapy that included tacrolimus, mycophenolate mofetil, and methylprednisolone. This case exemplifies how proactive consideration of transplantation can dramatically improve outcomes for patients in regions with limited dialysis access, benefiting both the patient and their family caregivers.
Discussion
This case demonstrates the successful implementation of kidney transplantation as a strategic solution for patients in disaster-affected regions with limited dialysis access. Thirteen years after the Great East Japan Earthquake, this patient’s successful transition to transplantation significantly improved the quality of life for both herself and her family caregivers while reducing health care system dependencies. Her case offers valuable insights into how transplantation can effectively address persistent health care access challenges in post-disaster regions, particularly for suitable candidates who would otherwise face prolonged burdens from limited local dialysis availability.
This case illustrates why transplantation merits strong consideration in disaster-affected regions with limited health care infrastructure. Even 13 years post-disaster, the region’s dialysis facilities remain insufficient, requiring patients to travel 80 km thrice-weekly for treatment (Figure 1). The historical shortage of dialysis facilities was exacerbated by the disaster, and resource constraints have prevented significant expansion of services in areas like Minamisoma City. While Nishikawa et al. documented these access limitations 1 year after the disaster,Reference Nishikawa, Ozawa and Tsubokura4 our case demonstrates both the persistence of infrastructure challenges and how transplantation can effectively address them. Rather than waiting for expanded dialysis facilities that may not be economically viable in recovering regions, transplantation offers an immediate solution for suitable candidates while reducing overall health care system burden.
Map of the Coastal Area of Fukushima Prefecture Showing Minamisoma City, Iwaki City, and the Fukushima Daiichi Nuclear Power Plant
While receiving dialysis, the patient ultimately chose to undergo kidney transplantation. In Japan, dialysis treatment is subsidized through National Health Insurance, the High-Cost Medical Expense Benefit system, and the Self-Support Medical Care program, resulting in minimal out-of-pocket expenses for patients. In contrast, although the costs of immunosuppressive medications and routine follow-up examinations after kidney transplantation are covered by insurance, comprehensive welfare support comparable to that provided for dialysis remains limited. Despite these circumstances, it is likely that patients elected to undergo kidney transplantation based on the perceived advantages associated with the procedure.
Previous research has documented significant physical and mental health impacts on dialysis patients in disaster regions,Reference Haga, Hata and Yabe6, Reference Hyre, Cohen and Kutner7 particularly focusing on travel-related burdens.Reference Ozaki and Tsubokura8 Stephens et al. demonstrated that increased travel distance for dialysis correlates with higher mortality and decreased quality of life.Reference Stephens, Brotherton and Dunning9 Our case powerfully illustrates how transplantation can address these challenges. Before transplantation, the patient faced multiple barriers: thrice-weekly long-distance travel, dependence on her father for transportation, and limited ability to pursue employment. These challenges align with studies showing how disaster-related health care disruption can create sustained family burden.Reference Hori, Ozaki and Murakami10 For younger patients, especially, such restrictions on social engagement and career development can significantly impact well-being. Transplantation effectively resolved these issues, enabling greater independence and improved quality of life for both the patient and her family, while supporting her professional aspirations.
This case demonstrates how kidney transplantation can effectively address health care challenges in disaster-affected regions. While transplantation requires specialized centers, its success in improving patient outcomes suggests it should be considered as a primary strategy in disaster recovery planning, alongside other innovations like mobile dialysis units and telemedicine. Rather than viewing transplantation as just an alternative to local dialysis facilities, this case shows its potential as a transformative solution that can both enhance patient care and reduce infrastructure burden in medically underserved areas. Future disaster preparedness policies should incorporate transplantation as a key component of comprehensive health care recovery strategies, particularly in regions prone to natural disasters.
Conclusion
This case demonstrates how limited access to dialysis facilities in disaster-affected regions can influence treatment choices. Kidney transplantation proved highly effective in reducing both patient and family burden of care, suggesting its value as a treatment option in areas with limited dialysis access. The persistent health care challenges 13 years post-disaster underscore the need for comprehensive recovery strategies, with transplantation representing a viable long-term solution for suitable candidates.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Competing interests
None.
Ethical standard
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
