To learn more about how Fresenius Medical Care is successfully delivering high quality dialysis therapy to patients, click here to read our study published in the Clinical Kidney Journal.

If you'd like to assist those in Ukraine, please consider donating to the Fresenius Medical Care Cares Fund by clicking here. 

Dr. Michael Kraus: Welcome, everyone, to this episode of Field Notes. I'm Dr. Michael Kraus, the Associate Chief Medical Officer for Fresenius Kidney Care, and your host for this discussion today. Here we interview the experts, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day. 

We have a fascinating episode for you today. We're taking you behind the scenes in Ukraine to give you a firsthand look at how a group of heroic individuals are able to provide critical dialysis care to patients during the conflict.

Before the war, Fresenius Medical Care's dialysis network in Ukraine operated three dialysis centers. They were located in Cherkasy, Chernihiv, and Kharkiv, providing dialysis therapy to 349 end stage kidney disease patients. Two of these centers, Chernihiv and the newly built Kharkiv, were blockaded in the first days of the war. Yet, patients still received life sustaining care. 

Here to talk about how Ukraine dialysis staff organized to be able to provide lifesaving therapy to patients are Dr. Stefano Stuard, Senior Vice President and Chief clinical Officer of Europe, Middle East, and Africa. And also joining us today is Dr. Volodymyr Novakivskyy, the Country Medical Director in Ukraine. 

Stefano, Volodymyr, thank you so much for being here today to discuss such an important topic.

Dr. Stefano Stuard: Thank you, Michael. It's a great pleasure to stay with you.  We like to tell everybody the story of Ukraine.  Because they are the first doctors in the story of Ukraine and dialysis at Fresenius Medical Care.

Dr. Volodymyr Novakivskyy: Thank you. Thank you for the invitation. It's really important for us that we can explain. We can introduce this not very pleasant story, maybe, but we can introduce it for everybody and explain how we do our job in such circumstances.

Dr. Michael Kraus: Stefano, let's start with you and talk about the discussions with patients prior to the invasion. There were significant concerns about the potential for an invasion long before February of ‘22. How do you prepare patients for the potential for war? What measures did you take?

Dr. Stefano Stuard: I have to say that this task was received by our Ukrainian colleagues instructing the patients in order to avoid any excessive protein intake, avoid fluid overload, avoid intradialytic quick gain. And also very important, instruct them about self-connection just in case there were emergency or crisis. So, this was really well done at patient level. And I think that our Ukraine colleagues also were able to select those patients that deserved more assistance just in case there were an emergency to be solved

So, and this was really well done by instructing the patients, reinforcing the messages. And at the end of the story, I have to say that was a great success.

Dr. Michael Kraus: It's amazing. I could just imagine how horrifying it might be to think that I couldn't get my life saving therapy and what do I have to do to survive until I get it? It's just fascinating. And Volodymyr, you are a practicing nephrologist in Ukraine, managing care delivery and caring for patients at the ground level. What part of Ukraine do you live in?

Dr. Volodymyr Novakivskyy: I live in Cherkasy. I was first the head of this biggest center in Ukraine, our biggest center. So, my job is to support all centers of Fresenius in Ukraine. But my destination was in the middle of Ukraine and Cherkasy. 

Dr. Michael Kraus: As a nephrologist, I can only imagine. What were you thinking before February? What were you thinking before the invasion started? And how were you planning?

Dr. Volodymyr Novakivskyy: You know, in that time, we received some information about Russian troops around Ukraine. And certainly, we prepared our centers for some extraordinary things. We made stock for three months for medicines, for disposables, and so on. It was our common life, common practice, which is the usual not only for Ukrainian Country Medical Director, but for all nephrologists all over the world.

Dr. Michael Kraus: Two of our centers, you know, Chernihiv and Kharkiv, are right in the in the war zones. How are the patients cared for in those locations? How do you go about protecting patients, employees and even family members? And were you able to deliver the same quality therapies or were there significant fluctuations from the usual three times a week dialysis?

Dr. Volodymyr Novakivskyy: You see, it was separate decisions for every region, really, because in the Cherkasy center, we have no battles and combat attacks. It was out of a war zone. And so we had the best solutions for our patients because we can deliver the best quality of care, maybe only to reduce some damage this time because of curfew.

But very difficult situation was surely in Kharkiv. And also the worst situation was in Chernihiv because the city was surrounded by Russian troops in the first days of the war. In Kharkiv, it was very good railway connection with western part of Ukraine. And in the beginning of March, we decided to evacuate all patients from Kharkiv to help not only for patients, but for their relatives also to evacuate in Western part, and our staff members helped to everybody to reach a railway station. So, the partner clinic met them in and they helped them to accommodate to receive good care, and yeah, so this problem was solved. 

But in Chernihiv, it was much more difficult as a third city was rounded by Russian troops, and it was not very good connection with any other transport. And for a long time, till the end of March, they stayed there. And fortunately, by the middle of March, we have the electricity, and we have water supply in in our center.

And the most important thing that we had there, a very big basement. In this basement, we can organize dialysis, and we can organize accommodation for many of our staff members, for patients who were from the battle zones and so on. Great efforts from different people, from different organization lead to evacuation in the end of the March.

But week before all our people there and patients and staff stay without electricity, without water supply, so dialysis was impossible. Our physicians, our nurses take care of patient, try to explain to them how to eat, how to drink, and how to support their lives. So I'm very proud of these efforts because nobody die without dialysis for this time.

Dr. Michael Kraus: You were able eventually to move people out of the war zones. But for quite a while, for that month Chernihiv, you actually kept patients, employees, family members, and even pets.

Dr. Volodymyr Novakivskyy: Yes.

Dr. Michael Kraus: In the dialysis unit, because travel is hard, right?

Dr. Volodymyr Novakivskyy: Yes, yes.

Dr. Michael Kraus: And then even moved the dialysis unit, as I understand it, from the third floor down to the first floor in a very short period of time.

Dr. Volodymyr Novakivskyy: Yes. Yes. And fortunately, we had enough dialysis places in Cherkasy. And all these patients from Chernihiv were evacuated to Cherkasy center.

Dr. Michael Kraus: And it was done safely and well. Stefano, let's switch to you for a second. Water and electricity are paramount to dialysis treatment. We don't have water, we don't have electricity, we don't deliver therapy. What sort of things did we arrange to make sure we could safely continue to dialyze?

Dr. Stefano Stuard: I strongly believe that in the first phase of the war that it was a strategy of the Russian army in order to create problems to civilians trying to destroy the water supply and the electricity supply. And these were the problems that our dialysis centers faced in Chernihiv and also in Kharkiv. So, from Germany, we tried to support our Ukrainian colleagues by delivering to them electricity generators in order to avoid any problem with electricity supply. 

For the water, I have to say that this is really the bottleneck is the problem that each dialysis center can face during disasters. As Volodymyr mentioned, this was a problem that they faced one week and not every day and not every day. This was the problem. Not every day, the water supply problems. So, at the end of the study, they were able to continue dialysis treatment with the exception of the last week, when they moved the patients from Chernihiv and Cherkasy. We anticipated a little bit from Kharkiv, but in Chernihiv was the problem. But at the end, this problem was solved without any specific sufferings related to lack of dialysis for these patients.

Dr. Michael Kraus: We moved patients to Cherkasy eventually. What was that evacuation process like, watching it from your location versus being in Ukraine? What were your thoughts and how comfortable were you in moving these patients?

Dr. Stefano Stuard: That was a difficult, difficult task for all our Ukrainian colleagues to move these patients. More difficult because we requested that the patients should not be alone, but we also supported the presence of family members together with the patients. And you mentioned also that because it's very important, very important to remember the support who all the patients.

So, and for this I have to thank the areas of our Ukrainian colleagues because they did a wonderful job using their cars in order to bring the patients to the rail station and discussing also with the Minister of Defense in order to try to support the transfer of the patients to the rail station. 11:55: But I think that Volodymyr here can go better in detail, explaining all the difficulties that the Ukrainian colleagues were able to manage.

Dr. Michael Kraus: So, Volodymyr, you have three units and you move two units to your Cherkasy unit, that must have put some sort of stress on the units in place. What was that like? How did you accommodate for those extra patients in Cherkasy?

Dr. Volodymyr Novakivskyy: Fortunately, this problem helped to solve by our local administration and majority of patients were located in one of our hospitals, city hospitals, in Cherkasy. So, then we tried to deliver them everything that we can. Clothes, meals, and so on. It was a difficult task for first few days maybe, and then the situation normalized. Everyone was out of danger, and they started to receive good treatments, and they started to live a more creative life I can say.

Dr. Michael Kraus: Such a wonderful story of working together to provide quality to people in the worst possible time. Just, just fascinating. Stefano, I know that you live and breathe the quality of throughout all of Europe and Africa and the Middle East, actually. How do you go about monitoring the quality that we deliver in Ukraine and speak a little bit about how actually excellent that quality was?

Dr. Stefano Stuard: I'm very proud to say that before the war in Ukraine, almost 98% of the patients dialyzed in our clinics received hemodiafiltration treatments. And I am also very proud that these treatments were not stopped during the war. Also, when we moved and transferred from Kharkiv and from Chernihiv to Cherkasy. 

So, what was reduced was the treatment time in order to try to accommodate all patients. And slowly they recover the treatment time so at the end of the study, they were able to manage the right dialysis treatment, utilizing the resources that they have. 

How we manage the quality, how we evaluated the quality? So also during the war, all the data recorded from our dialysis machines, from the laboratory tests were recorded in Euclid, and we were able to see this data. And also, Volodymyr and also the Ukrainian clinical staff were able to see this data in Euclid, understanding the performances, the quality performances of patient lives. 

And also I would like to mention that they were also able to evaluate remotely the performances from dialysis centers before the patients were transferred to Cherkasy. 

So at the end of this story, let me say something: Here we have to take in consideration two different aspects. The ground that was the area and the patriotism of our patients in Ukraine personally, and also the commitment of our clinical staff, physicians, and nurses. But then this base ground was very solid because that it was accompanied by Fresenius Medical Care, that was they must deliver the best from Germany, from the West, to our European colleagues in order to try to support as much they were able to do for their patients and also offering hospitality not only to our patients for Fresenius medical care patients, but also to those patients that had to receive dialysis treatment because they move from other centers to our center.

Dr. Michael Kraus: And it's fascinating, we're able to keep that up even in times of war. And what we're talking about war, unfortunately, war brings trauma to everybody and especially soldiers, which unfortunately leads to acute kidney injury in many. Volodymyr, from a nephrologist point of view, what impact did that have?

Dr. Volodymyr Novakivskyy: War trauma on everybody had a great impact on health care system, you see, and certainly the quantity of acute kidney injury was very high and now it's also very high. And so great efforts was done from my side, first of all, to improve quality of kidney care in the acute segment. In our country, is not very popular CRT therapy. So, it was one of my tasks to have lessons with physicians to educate them how to do it, to deliver some humanitarian aids in hospitals and to help in such difficult times to improve this segment of care in first of all, in the anesthesiology departments.

Dr. Michael Kraus: And as a physician and a caregiver, you have to throw the politics aside, don't you? Because the patient in front of you can be from anywhere. How is that care delivered?

Dr. Volodymyr Novakivskyy: Uh, if we speak about our centers, it’s very simple, but if we're starting to speak about the hospital, sometimes it can be difficult because knowledge is of all physicians different, and sometimes they can explain everything in half an hour. Sometimes it takes a lot of time, more than one day, two days.

Dr. Michael Kraus: And the care you deliver to every patient was the same regardless of what country of their origin was, correct?

Dr. Volodymyr Novakivskyy: Yes. Yes.

Dr. Michael Kraus: Everybody deserves the best care possible. And you guys clearly did that. Stefano, go ahead.

Dr. Stefano Stuard: Let me go to an important point, because we are now speaking about Ukrainian patients that were treated in our dialysis centers and they moved from our dialysis centers to our dialysis centers.  

We have also to mention that our dialysis centers in other neighboring countries. I am referring, for example, to Poland, to Romania, to Slovakia, to Slovenia. They opened their dialysis centers for refugees that requested dialysis treatment. We should take in consideration that Fresenius Medical Care, as a company did a wonderful job welcoming all these patients, and I would like to mention, not in a comfortable moment because we are speaking about COVID-19 peaks in Europe.

So, what does it mean? Isolating these patients, making COVID-19 tests, making hepatitis B antigen test… so all our dialysis centers in the member countries and also in Ukraine did a wonderful, wonderful job. And we should recognize that for the company. 

And now let me say about another topic that maybe Volodymyr would disagree. But I have to say this. Also, our Russian colleagues in our network and dialysis centers offer their hospitality in order to support refugees if they wanted to move, not in the direction of the West, but in the direction of the East. So, I have to say that Fresenius Medical Care as a company and Fresenius Medical Care employees did a wonderful job in all of the direction, east, west, north, south.

Dr. Michael Kraus: Absolutely, it's about taking care of patients, even during difficult times. I think Volodymyr and the whole area really came to the front, and we don't have time to talk about quality, but you've told me before the quality provided during the conflict has been great, and actually in Ukraine now, it's in some of the best in all of Europe.

This could really be a fantastic case study, frankly, on the best practices for medical care during war. Literature on this topic is scarce. This is such an important conversation to have and crucial information to spread. It's important to note that this is about care for all patients, regardless of nationality, race, or gender. Our job is to deliver the best care to all of these patients. And I know this is a priority for us and you in Ukraine and throughout the globe. This is about patients and not politics. I'm proud of the efforts and care that you've provided.

Stefano, Volodymyr, thank you very much for your time and thank you very much for everything you've done and are still doing for our patients during this war.

Dr. Stefano Stuard: Thank you, Michael. We are speaking every time about quality of care that we are committed to deliver high quality of care. But I would like to mention that everybody has a heart and everybody are teaching patients with love. Okay? This is really important to see. Now, I believe that our colleagues in Ukraine, what they have done, they have done with their love, because this is very important to mention.

Dr. Michael Kraus: And Volodymyr, any parting thoughts?

Dr. Volodymyr Novakivskyy: Thank you, Michael. I can say that really, I didn't want to have such experiences. Yes. But I only know that I, not only me, everyone around me knows that we must do it. And we must do everything to save people, to deliver care to them in all circumstances. So I think from our side, we do everything we should. We must do.

Dr. Michael Kraus: Again, thank you both for joining us.

And to our audience, thank you for joining us today. If you would like to read further about this journey in care in Ukraine, you can find a very good article entitled “War Ukraine and Dialysis Treatment: Human Suffering and Organizational Challenges” with Dr. Novakivskyy as the lead author in the Clinical Kidney Journal, published January 25th, 2023. It is open access and online. 

If you'd like to assist those in Ukraine, please consider donation to the Fresenius Medical Care Cares Fund. The link can be found at the top of the episode page at fmcna.com. 

If you're new to the Field Notes podcast, you can download past episodes in the Apple Store, Google Play, or wherever you download your favorite podcasts. Please remember to subscribe so you can receive the very latest updates as they occur. 

Until next time. I'm Dr. Michael Kraus, and you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone, and let's begin a better tomorrow.