Nephrol Dial Transplant (2012) 27: 1277–1281
Crush recommendations: a step forward in disaster nephrology
R. Vanholder1and M.S. Sever2
1Nephrology Section, University Hospital, Ghent, Belgium and2Department of Nephrology, Istanbul School of Medicine, Istanbul,
Correspondence and offprint requests to: R. Vanholder; E-mail: email@example.com
In a supplement of Nephrology Dialysis and Transplanta-
tion, appearing simultaneously with the present issue, rec-
ommendations for the prevention and treatment of crush
syndrome are published . This monograph contains 85
recommendations, 23 tables, 9 figures and 376 references.
Prepared by a workgroup of nephrologists, intensivists,
surgeons and logisticians, they emanated out of a joint
effort of European Renal Best Practice (ERBP)  and
the Renal Disaster Relief Task Force of the International
Society of Nephrology (RDRTF/ISN).
Crush is a condition which carries a high risk of mor-
bidity and mortality [3, 4]. The number of earthquakes
necessitating nephrologic intervention because of crush
is steadily growing [5–11]. Next to poor quality of build-
ings and overpopulation in endangered areas, this evolu-
tion can also be attributed to improved rescue and higher
awareness of the renal complications of crush, the latter
being brought about in part by interventions of specific
nephrologic intervention teams. RDRTF/ISN, the first
nephrologic relief organization [12, 13], embedded its
rescuers in specialized non-nephrologic teams (belonging
to Me ´decins sans Frontie `res – MSF) enabling backing in
areas where (para-)medical personnel lacks know-how,
such as logistic support.
Inspite ofmanysaved lives,the consecutive interventions
also revealed several weaknesses open to improvement.
First, the medical expertise of the few practiced renal rescu-
ers could insufficiently be disseminated over the many in-
dividual medical professionals taking care of crush patients.
rologists, most of whom have low exposure to crush in
everyday practice. In addition, however, it also concerned
other specialists or generalists who have limited experience
with Acute Kidney Injury (AKI). Second, the existence and
contact coordinates of renal relief teams remained often un-
known to other relief organizations or to local specialists
who after earthquakes coincidentally got involved in treat-
ment of crushed victims without being prepared.
The crush recommendations which are commented in
this editorial hopefully cope with these problems, forward-
ing a structured approach to treat crush and associated
sequence of phases a victim traverses (Figure 1): approaches
before, during and after extrication, in the field, during trans-
conservative and dialysis treatment). Finally, logistic organ-
ization, advance planning and implementation are covered.
In what follows, we summarized nine prominent topics:
fluid administration, hyperkalaemia, hypocalcaemia, acido-
sis, fasciotomy, amputation, dialysis, planning and logistic
organization. We refer to the corresponding recommenda-
tions and tables between square brackets [ ].
This editorial does not replace the proper recommenda-
tions, which are more comprehensive, offer in depth ther-
apeutic instructions and contain structured guidance rules
together with their rationale. The interested reader is there-
fore referred to the full publication .
While an equilibrated fluid status and an adequate perfu-
sion of the kidneys are essential for all imminent cases of
AKI, intravascular hydration is even more imperative in
rhabdomyolysis and crush, due to the preferential seques-
tration of large quantities of fluid in the injured muscles
[14, 15]. Together with direct toxic effects of myoglobin
and intra-tubular obstruction due to deposition of myoglo-
bin and uric acid, this dehydration is the main cause of
AKI. Hence, the cornerstone of prevention of AKI in
crush is the timely administration of large quantities of
appropriate fluid. Main points of attention are timing,
quantity and fluid composition.
? The Author 2012. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
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