Survival under armed conflict: displacement, dialysis continuity, and financial burden among hemodialysis patients in Sudan.

Abstract

Background: Patients receiving maintenance hemodialysis are highly vulnerable during armed conflict, particularly when healthcare systems are disrupted. However, factors associated with survival under prolonged disruption remain poorly understood. This study examined survival and key associated factors among hemodialysis patients during the armed conflict in Sudan.

Methods: We conducted a retrospective cohort study of 158 adults receiving maintenance hemodialysis in Khartoum, Sudan, at the onset of the April 2023 conflict, with follow-up extending up to 18 months. Outcomes were confirmed for 122 patients, while 36 were untraceable and censored at their last verified contact. Participants were categorized according to displacement trajectory within the first three months. The primary outcome was survival. Key variables included displacement trajectory, dialysis frequency during follow-up, and out-of-pocket costs. Risk ratios and time-to-event approaches were used to examine associations, with sensitivity analyses conducted to assess the impact of loss to follow-up.

Results: Of the 122 patients with confirmed outcomes, 53.3% remained alive at the end of follow-up. Survival rates differed across displacement trajectories: 81.8% among those who relocated internationally early, 53.3% among those who achieved internal settlement, 34.6% among those who experienced secondary displacement, and 13.8% among those who remained in the capital. Higher survival was observed among patients receiving at least two dialysis sessions per week compared with those receiving one or fewer sessions or emergency-only dialysis (68.8% vs. 43.2%; RR 1.59, 95% CI 1.15-2.20). Financial burden was substantial, with monthly dialysis-related costs ranging from USD 720-3,600 during early displacement and remaining high thereafter (USD 500-3,500).

Conclusions: Survival differed across displacement patterns and dialysis continuity, and was influenced by financial burden. These findings underscore the need for conflict-adapted dialysis strategies and improved financial protection for patients reliant on life-sustaining therapies.