Organization of the specialized medical care in conditions of limited resources (military status) (on the example of the provision of nephrology aid in Ukraine)

. The paper considers the features of the provision of pediatric and adult nephrology medical care during martial law in Ukraine from February 2022 to May 2023. The influence of military stages on the nephrology care are presented, territorial zones during the conflict are highlighted, event tracks are shown. Separately, the activity of the Ukrainian Association of Nephrologists/Ukrainian Association of Pediatric Nephrologists, new opportunities for integrating nephrology into the system of medical knowledge are considered. Along with the negative trends, positive results were revealed that made it possible to move forward in the system of specialized medical care, namely an increase in transplant activity, a wider use of “long” treatment regimens with rituximab, and the use of digital kidney biopsy. Statistical data, SWOT analysis at the stages of the military conflict are given, an analysis is presented for refugees who left for the European Union to receive kidney replacement therapy. The enormous role of humanitarian programs for maintaining the structure of nephrological care in Ukraine is emphasized. The accumulated experience is unique and can serve as material for the analysis of similar situations in the world in the future.

Let's analyse the structure of pediatric nephrology care in Ukraine in this time. In almost every region there is a pediatric nephrology department and in total there are 114 pediatric nephrologists in the country. We have approximately 65 thousand children and 25 children with CKD per one PN. During the war, all these figures decreased very significantly, but then levelled off. Currently, there is a shortage of both pediatric nephrologists and medical personnel in general across the country. Each region has a chief pediatric nephrologist, until 2017 there was a chief pediatric nephrologist of the Ministry of Health of Ukraine, and Prof. D. Ivanov has been occupying this duty for more than 10 years. During the war, the number of children's nephrology departments decreased in proportion to the annexed territories, but the number of dialysis departments was maintained (Fig. 1 has professional medical journal Kidneys, a website, and two regular CME annual training courses REENA (Renal Eas tern Europe Nephrology Academy) and WKD CME course (Fig. 2). During the war the courses have been organized in hybrid mode [4]. World Kidney Day CME course 2023 "Kidney health for all. Focus on inclusion for disabled children and adults with CKD" was held in a hybrid format on the largest professional web platform for doctors Accemedin, which allowed to increase the number of views of our course to 14.5 thousand compared to the usual 500. This is a huge data for Ukraine. In September 2023, UAN/UAPN are going to organise 18 th REENA course.
The world community has supported UAN/UAPN in its activity in the war time [6]. Almost every month Prof. Dmytro Ivanov, the President of UAN/UAPN has had a presentation at the largest international forums.
To facilitate the ongoing training of pediatric nephrologists and nephrologists, the nephrology week have been initiated on web platform Accemedin and received a huge number of views -almost 62 thousand. It turned out to be a top not only for nephrologists, but also for the medical audience in general. UAN/UAPN are in a burning trend. From May 2023 the new project Nephrology Wednesday with one lecture in nephrology every following week have been started for doctors. It became already successful with over 1,000 views for each lecture (Fig. 3).
In pre-war time there are 320 children with CKD per 1 million children, in our opi-  Оригінальні статті / Original Articles nion, many children are still outside our care. Over the past 5 years, the number of children with CKD 5 has had a clear downward trend. We tend to think that this is due to the active policy of renoprotection. Renin-angiotensin inhibitors have been used in children in Ukraine for almost 20 years, last years the use SGLT2 inhibitors has been started [4]. At the same time, the number of children with CKD 5 receiving RRT remains virtually unchanged. In recent years, these children practically do not die. The prevalence is much less in Ukraine, the incident is nearly the same compared to ESPN data. The average number of transplants is 12 per year, i.e. nearly half of the children with CKD 5 who are on dialysis receive transplants annually, 60 % have live kidney from their parents. Interestingly, the number of transplants has increased compared to the pre-war period due to the transfer of transplant activity from the center to western Ukraine, where humanitarian programs and support from abroad are most active [4]. Maybe this is my personal opinion, but now the possibilities of this region are higher than before the war, both in terms of equipment and medicines. In the first three months of 2023, 90 kidney transplants were performed in adults and children at 19 centers (Fig. 4).
An interesting trend deve loped for children since 2023: thanks to very active transplantation, the number of children on the waiting list began to decrease. in Ukraine in 2022, 12 kidney transplants were performed on children. Of these, 8 are from living-related donors, and 4 are from deceased donors. Three children are being stayed on the waiting list, one of them is in Belgium.
After additional funding and the adoption of the law on transplantation, the number of transplants is increasing from 2021. Laparoscopic method to a donor, the use of robotics, a simultaneous kidney operation and donor preparation began to be applied in Ukraine. Careful selection of a donor, modern immunosuppression, a biopsy with a result within a day (this is a digital laboratory in nephrology clinic) allowed us to significantly improve the results compared to previous years, although the results of graft survival are even lower than in the world. The transplanto logy team from Lviv is being the most active in 2022-2023 (Fig. 4).
In general, comparing 2021 and 2022, the number of transplants in adults increased by 12 % and in children by 84 %. This is due to the state policy of financial stimulation for transplantation, the implementation of legal regulations that allow transplantation not only from relatives, but also from the deceased donors. The Fig. 5 presents the history of the development of the military situation in Ukraine. The war began on February 24 and is now continuing for over 16 months. Four-time intervals should be singled out, which significantly changed the possibilities of renal replacement therapy. The first stage was the beginning of hostilities, which entailed all the exis ting changes. At first, there was confusion, and many people began to leave the country with their children. The supply of medicines was practically stopped, and the logistics chains of medical care were broken. The second period is characterized by renewing medical care, the third one which was characterized by the total limitation of electricity, and the fourth one -almost safe life in nonmilitary zones with the presence of air attacks [4,7].

Оригінальні статті / Original Articles
We could divide the entire Ukrainian territory into 4 zones from the red zone [3], where active clashes are taking place and there are civilians, to the green zone, where there have been no hostilities, but this zone takes on refugees from the red zone. The allocation of these 4 zones, in our opinion, is very important, as it allows us to understand the logistics of organizing patient care. The greatest load falls on the red zone, where it is extremely difficult to continue dialysis. It is carried out in bomb shelters, and basements, it is difficult for patients to get to the dialysis centre, they stay there overnight and, sometimes, live there with their parents. Some adult people do not receive dialysis, hide in basements, die from underdialysis, exacerbations of chronic processes, primarily CKD 4-5. The red zone is also characterized by an increase in the number of patients, both military and civilian, with acute kidney injury. This also places an additional burden on dialysis departments. The third zone is green. It is under a heavy burden in helping refugees, the number of patients has increased, and consumables are needed in greater quantities. And everywhere there is a problem of personnel: someone wants to work in the areas subjected to bombing, and in the areas where it is calm, the stuff worked in 3-4 work shifts. Currently, there are 2 principal zones in Ukraine: where it is calm and where there are active hostilities. In quiet areas, departments work there, the number of patients is restored and people arrive from internal evacuation zones, the number of personnel is increasing. But there is a violation of the logistics chains for the supply of medicines and supplies [8].
These two negative factors determined the situation in the country and in the provision of medical care. The first is the physical blocking of territories by the enemy's army, which led to a shortage of food, medicine and movement. The second, which has been going on for 6 months, is damage to the country's energy structure, which continuously disrupted communication and electrically dependent processes [9]. The state provided dialysis departments with electricity and water as elements of critical infrastructure. For outpatient cyclic PD, we received humanitarian assistance in the form of charging stations and batteries.
The first period of war is presented here using SWOT (Fig. 6). In state units and departments there was an outflow of medical workers, but not to the same extent as in private facilities [4]. The patients were confused. Movement around the city and some areas was practically stopped due to the bombing. So, in war time be prepared to move patients to other departments nearby, be prepared to supply patients with individual dialysis machines, have a double supply of dialysis and immunosuppressive therapy consumables to quickly respond to a changed situation, and be ready to attract health workers to replace those who have left their working places.
The first humanitarian aid to the central and eastern regions of Ukraine, to Kyiv began to arrive 3 weeks after the beginning of the war [4]. German Society for Nephrologists and for paediatric nephrologists, IPNA, Task Force Relief offered their assistance first and most actively and significantly [9]. From the first weeks of the war, our colleagues actively offered their help.
The first three months of hostilities are characterized by limited opportunities for renal replacement therapy. There is a dramatic decrease in the number of healthcare wor kers, in direct proportion to the decrease of the population. This leads to a limitation of the completeness and quality of renal replacement therapy. There was a shortage of supplies, which made it difficult to provide assistance to the remai ning patients and those who have arrived through internal migration. The result of these processes requires the creation of a reserve of medical personnel, optimization of the work of the remaining personnel, the involvement of medical personnel from other sources, and the accumulation of a reserve of consumables for dialysis, medicines, mobile dialysis machines and immunosuppressants [10].
The next problem was the violation of logistic chains for the supply of necessary consumables and medicines. We were faced with a paradoxical situation. On the one hand, a number of pharmaceutical companies simply distributed medicines, including very expensive ones, in order to free their warehouses and help the population. On the other hand, some warehouses for medicines were closed and many of them, finally, were simply destroyed. As a result, there was an imbalance between need and consumption in the direction, as a rule, of a shortage of consumables and medicines. Disruption of transport chains, passenger traffic, subway stops, and road travel difficulties due to numerous checkpoints and military controls worsened the delivery of both treatment products and the availability for patients to arrive at dialysis centres, receive medicines for maintenance treatment, and perform the necessary tests.

Оригінальні статті / Original Articles
How to solve such problems? We consider it necessary to have a 3-month supply of consumables and medicines, additional dialysis units or machines, additional transport in medical facilities, fuel for cars, food and water for patients and stuff. Very important is the availability of equipped bomb shelters, in which it would be possible to carry out procedures, stay overnight or live for short periods of time for both patients and medical personnel. At the same time, it is extremely important to have sources of communication with the outside world, family, and employees through mobile communications, instant messengers and the Internet [11,12].
An extremely important outcome of all these restrictions is the deterioration in the provision of medical care to patients, namely: a decrease in the number of dialysis procedures from 3 to 2 per week, a decrease in the number of fillings during peritoneal dialysis, an increase in complications du ring the course of the disease, and an increase in the number of graft rejections. Moreover, due to the practical stoppage of kidney transplantation in the red zone and its decrease even in relatively prosperous zones, the number of people requiring dialysis care has artificially increased [13].
How are these issues resolved? In hemodialysis -by increasing the duration of the procedure or intensifying it using extended dialysis, hemodiafiltration, selecting patients with preserved residual kidney function for 2-day dialysis, transferring from hemodialysis to peritoneal dialysis or vice versa, depending on the technical conditions, creating a reserve of dialysis machines and cyclers for peritoneal dialysis. It is important to maintain the place of transplantation whenever possible and increase transplantation activity in relatively safe areas. It is also important to create a reserve of iron medicines and erythropoietin, the number of which has increased significantly in patients due to malnutrition, stress and underdialysis [4,9].

Оригінальні статті / Original Articles
A recent SWOT analysis of the last months demonstrates the increasing risks for critical infrastructure, interruption of dialysis and procedures and operational activities. all our hospitals are objects of critical infrastructure; therefore, electricity and water are available almost without interruption. There was a next wave of emigration. As a result, there were free dialysis places in Ukraine with 602 patients who were taking care in EU (data from ERA Tack Force Ukraine and WCN'23 report) (Table 1, Fig. 7). It's documented, that up to the end of August 2022, less than 10 % of Ukrainian dialysis patients decided to flee their country since the start of the Russian-Ukrainian conflict and the majority of them chose as their place for dialysis a country neighboring Ukraine [14].
Let's put the above in a nutshell. The first three months of hostilities are characterized by limited opportunities for renal replacement therapy. The second phase is characterized by the restoration of the work of dialysis departments, and the restoration of the supply of medicines, primarily through humanitarian assistance. The third unfavourable phase -a drastic disruption of the continuous supply of electricity. According to official data, about 45 % of energy supply capacities have been destroyed. Electricity is out for intervals of 4-8 hours, and the power blackout schedule is subject to emergency adjustments and, therefore, is not always followed, which requires generators for ambulatory dialysis. We got some charging station from abroad as humanitarian support, so gave the possibility for continuous ambulatory PD with cyclers. There are no interruptions in the supply of water and electricity in hospitals, but we need to organize these facilities for home dialysis.
The presented data are quite well described and discussed in modern literature [15][16][17][18]. At the same time, they are dynamically changing, which requires a quick response from the doctors providing care [20,21].
The Fig. 8 shows a summary SWOT analysis. All these approaches to assessing situations and the analysis of our experience are summarized, evaluated and embodied in recommendations for patients and doctors.
Such documents become open to doctors, the purpose of this work is to improve the quality of care for our patients, to draw conclusions from the experience and mistakes, the desire to create the most convenient and effective methods of providing medical care during military operations.