Dialysis During a Flood: What to Do If You Cannot Reach Your Session, the 3-Day Emergency Diet, Fistula and PD Catheter Care, and Warning Signs That Cannot Wait

A question from flood areas: someone at home is on dialysis and the water has cut us off from the unit. What should we do?

Short answer: dialysis is a treatment that can be delayed very little. Contact the dialysis unit as soon as you know a flood is coming to ask for early dialysis or a backup unit. While you wait, cut fluid, salt and potassium strictly, and watch for the warning signs that need emergency care.

During floods, many families post requests for help because a relative on dialysis is trapped at home. This article summarizes evidence from major floods and storms worldwide: why missed sessions are dangerous, what to prepare, what to eat, how to protect a fistula or PD catheter, and when not to wait. It does not assess any individual case and does not replace advice from the patient’s own doctor and dialysis nurses.

1. Why missed dialysis during a flood is dangerous

Short answer: failed kidneys can barely remove water, potassium and acid on their own. The longer the gap, the more these build up, and disaster studies link missed sessions with more hospital admissions and emergency visits.

Lessons from Hurricane Katrina

Interviews with 386 hemodialysis patients from 9 New Orleans units (Anderson 2009) found that 44% missed at least one session and almost 17% missed 3 or more. Those who missed 3 or more sessions had 2.16 times the odds of hospitalization. Missing more sessions was linked with dialysis vintage under 2 years, living alone, not knowing the unit’s emergency plan, not evacuating before landfall, and being placed in a shelter. A mortality analysis (Kutner 2009) found no clear excess deaths, and the authors stressed ongoing disaster-preparedness education.

Even the routine 2-day gap carries more risk

A NEJM study of 32,065 hemodialysis patients (Foley 2011) found that the day after the 2-day weekend gap had higher rates of death, heart-failure admission and arrhythmia admission than other days. Longer gaps during a flood should therefore not be left to run.

Units: events per 100 patient-years, from Foley 2011

2. Before the water arrives: early dialysis, a backup unit and a kidney go-bag

Short answer: getting dialysis early, before the flood hits, is linked with fewer emergency visits, admissions and deaths. Call your unit about its emergency plan as soon as a flood warning is issued.

Evidence for early dialysis

After Hurricane Sandy, a study of 13,264 hemodialysis patients (Kelman 2015) found that 59% received early dialysis. In affected areas, 4.1% visited the emergency department, compared with 2.6% in unaffected states and 1.7% in the same region a year earlier, and 23% of those who went to the emergency department needed dialysis there. A second analysis of 13,836 patients (Lurie 2015) found that early dialysis was linked with lower odds of emergency visits (OR 0.80), hospitalization (OR 0.79) and death within 30 days (OR 0.72).

Have a backup unit, because dialysis clinics flood too

After Hurricane Harvey, 26 of 124 dialysis clinics (21%) in Harris County flooded, and official flood maps missed 42% of the clinics that flooded (Kaiser 2021). In the 2024 southern Brazil floods, which affected more than 2.4 million people (Silva 2025), no deaths from lack of dialysis were reported, thanks to patient relocation, reallocation of machines and telemedicine. Ask your unit in advance where you should go if it closes.

Kidney go-bag (pack in waterproof bags)

• Documents: ID, health coverage card, dialysis unit name and phone, schedule, dry weight, latest treatment summary and blood results
• Medicines: at least 7 days of regular medicines, a list with doses, phosphate binders, and a potassium binder if your doctor has prescribed one
• 3-day emergency food: see section 3, plus small bottles of water
• Peritoneal dialysis: PD fluid and supplies as your PD unit recommends, masks, alcohol gel, gauze and waterproof dressings
• Other: torch, phone power bank, and gauze for pressing on a bleeding fistula

4 steps when a flood warning is issued

3. The 3-day emergency diet when dialysis is delayed

Short answer: eat less than usual of fluid, salt, potassium and protein so waste builds up more slowly until you can dialyze. This plan only buys time; it does not replace dialysis.

Daily targets in the emergency plan

The US National Kidney Foundation (NKF) emergency meal plan for hemodialysis limits fluid to about 2 cups (roughly 500 mL) a day and lowers protein, sodium and potassium from the usual diet. A Korean study (Jang 2025) designed 3-day emergency menus for hemodialysis patients, both with and without electricity and water, keeping potassium, phosphorus, sodium and fluid tightly limited. A systematic review of 15 studies (Smith 2020) supports teaching emergency diets in advance.

Easing thirst

• Eat less salt, because salt is the main driver of thirst
• Suck small ice chips, chew gum, or rinse your mouth and spit
• Use a small cup, and take pills with a single sip
• Count soup, broth, rice porridge and ice as fluid

Food from relief teams

Instant noodles, canned fish and other canned foods are high in salt. If there is nothing else, use no more than half the seasoning packet, do not drink the broth, drain the liquid from cans, and eat small portions. Tell volunteers you are on dialysis and ask for plain rice or bread instead of salty dishes.

Foods to choose and avoid while dialysis is delayed, to use alongside advice from your dietitian or dialysis nurse (shown as cards on mobile)

4. Caring for a fistula, dialysis catheter and PD catheter during a flood

Short answer: floodwater is contaminated, and a dialysis access is a direct route for germs into the blood or abdomen. Keep it covered from water, check it daily, and go to hospital at the first sign of infection.

Arm fistula or graft

• Keep the fistula arm out of floodwater; if it gets wet, wash with clean water and soap, then dry
• Feel for the thrill once a day; if it has gone, go to hospital immediately
• No blood-pressure cuffs, heavy carrying or sleeping on that arm
• If it bleeds, press firmly with clean gauze for 10 minutes; if it does not stop, call emergency services

Dialysis catheter in the neck or chest

This catheter leads straight into a large vein. Keep the site and dressing dry at all times and never soak it. Fever, chills, or redness and pus around the catheter mean hospital now, because bloodstream infection spreads fast.

Peritoneal dialysis

A study of 101 PD patients after the 2023 earthquake in Turkey (Sahutoglu 2024), 79 of them on manual exchanges, found power outages and shortages of clean water, and 12 had delays in their PD program. During a flood:

• Store PD fluid and supplies high and dry, in the quantity your PD unit recommends
• If you use automated PD, practise manual exchanges in advance in case of power cuts
• Clean hands with bottled water or alcohol gel, and wear a mask before every exchange
• Cover the exit site with a waterproof dressing; if floodwater touches it, clean it as trained and tell your PD nurse
• Cloudy drained fluid, abdominal pain or fever may mean peritonitis: keep the bag and go to hospital immediately

5. Other flood hazards for people with kidney disease

Short answer: leptospirosis, diarrhea, dehydration and some medicines can injure the kidneys or cause dangerous acidosis, especially in people with chronic kidney disease who are not yet on dialysis.

Leptospirosis and wound infection

Wear boots, avoid wading unless necessary, and wash any wound with clean water straight away. Fever, muscle pain especially in the calves, or red eyes after wading need a hospital visit. Many dialysis patients already pass little urine, so a fall in urine output cannot be used as a warning sign; watch for fever and other symptoms instead.

Metformin when you have diarrhea or cannot eat

A report of 12 patients from the major Hat Yai floods in late 2025 (Phongphithakchai 2026) described severe metformin-associated lactic acidosis with acute kidney injury, triggered by poor intake, dehydration and continuing the medicine while ill. All needed urgent kidney replacement therapy, and all survived. Family members with diabetes and reduced kidney function who develop diarrhea, vomiting or cannot eat should ask a doctor or pharmacist about pausing the medicine, and go to hospital for deep rapid breathing, severe weakness or drowsiness.

Other medicines to watch

• Do not buy NSAID painkillers such as ibuprofen or diclofenac on your own; they raise potassium and harm remaining kidney function
• If you use insulin or glucose-lowering pills and are eating less, watch for low blood sugar and ask your doctor about dose changes
• Kidney transplant recipients must keep taking immunosuppressants on time, never stop them on their own, and take extra care to avoid floodwater infections

6. Options when you cannot dialyze at your usual unit

Short answer: the best option is to dialyze on schedule, at whichever unit you can reach. Diet and medicines only buy time. This table uses generic names and drug classes only.

Comparison of options during a flood

Comparing dialysis, peritoneal dialysis, diet and medicines for people with kidney failure during a flood (shown as cards on mobile)

Frequently asked questions (FAQ)

Questions families of dialysis patients often ask during floods

If a flood stops me from getting to dialysis, how many days can I wait?

People on thrice-weekly hemodialysis should try to dialyze within 2–3 days of their last session. A study of 32,065 hemodialysis patients found that even after the routine 2-day weekend gap, deaths on the following day were higher than on other days (22.1 vs 18.0 per 100 patient-years), and after Hurricane Katrina, patients who missed 3 or more sessions had 2.16 times the odds of hospitalization. The 3-day emergency diet only buys time; it does not replace dialysis.

Who should I contact if I cannot reach my usual dialysis unit?

Call your own unit first to ask for early dialysis or help finding a backup unit. If you cannot reach them, contact the nearest hospital that is still open, and tell rescue teams or shelter staff that you are on dialysis and when your last session was. In Thailand, call 1784 (Department of Disaster Prevention and Mitigation) for transport help, 1330 (National Health Security Office) about coverage at another unit, and 1669 immediately for emergency symptoms. Elsewhere, use your local emergency number.

What should I eat while my dialysis is delayed?

Eat less than usual of fluid, salt, potassium and protein so waste builds up more slowly until you can dialyze. The US National Kidney Foundation 3-day emergency plan limits fluid to about 2 cups (roughly 500 mL) a day and lowers protein, salt and potassium from your usual diet. Choose white rice, white bread, plain crackers and low-potassium fruit; avoid bananas, oranges, coconut water, tomatoes, potatoes, dried fruit, sports drinks and dark colas.

Can dialysis patients eat relief food such as instant noodles and canned fish?

In small amounts, if nothing else is available. Instant noodles and canned food are very salty, and salt drives thirst and swelling, so use no more than half the seasoning packet, do not drink the broth, drain the liquid from cans, and eat small portions. Avoid watery rice porridge, which counts as fluid. When receiving donations, tell the volunteers you are on dialysis and ask for plain rice or bread instead of salty dishes.

How much can I drink while dialysis is delayed?

Emergency plans for hemodialysis limit fluid to about 500 mL a day, including water for pills, soup and liquid foods. If you still pass a good amount of urine, your doctor may allow more. To ease thirst, eat less salt, suck small ice chips, chew gum, use a small cup and take pills with a single sip. Go to hospital immediately if your weight rises fast, you swell, become breathless or cannot lie flat.

What should I do if my fistula arm gets into floodwater?

Try to keep the fistula arm out of floodwater, especially if there are wounds or needle marks. If it gets wet, wash with clean water and soap, dry it and watch for infection. Check once a day that you can still feel the thrill or hear the bruit, and do not take blood pressure or carry heavy loads on that arm. Go to hospital immediately if it becomes red, hot, swollen or pus-filled, you develop fever, or the thrill stops. A dialysis catheter in the neck or chest must stay dry at all times; fever or chills mean hospital now.

What should people on peritoneal dialysis prepare during a flood?

Store PD fluid and supplies high and dry, in the quantity your PD unit recommends. People on automated PD should practise manual exchanges in advance in case of power cuts. A study of 101 PD patients after the 2023 earthquake in Turkey found power outages and water shortages, and 12 had delays in their PD program. Clean hands with bottled water or alcohol gel before every exchange, and keep the exit site covered from floodwater. If the drained fluid is cloudy, or you have abdominal pain or fever, keep the bag and contact your PD unit or hospital immediately.

Which symptoms mean a dialysis patient must call emergency services during a flood?

Call emergency services (1669 in Thailand) immediately for breathlessness or being unable to lie flat, palpitations or an irregular heartbeat, weak or numb limbs, chest pain, confusion or unusual drowsiness, seizures, fistula bleeding that does not stop after 10 minutes of firm pressure, high fever with chills, or fever with calf pain after wading through floodwater. Tell responders you are on dialysis, when your last session was, and which medicines you take.

Scientific mechanism

Summary by Asst. Prof. Dr. Norawit Raatpiboon:
healthy kidneys remove potassium, water, salt and acid every day. In kidney failure, that job moves to the dialysis machine or PD fluid. Between sessions, potassium from food and from cells accumulates in the blood; at high levels it disturbs the electrical activity of heart muscle, causing arrhythmias or cardiac arrest. At the same time, water and salt stay in the circulation, increasing the load on the heart and leaking into the air sacs of the lungs, which causes breathlessness and inability to lie flat. This is why the 2-day gap carries more cardiac events than other days, and why longer gaps during floods raise the risk further.
Salt concentrates the blood and triggers the brain’s thirst centre, so cutting salt controls fluid better than restricting water alone. High-protein foods add nitrogen waste and acid, so a temporary protein reduction slows uremic symptoms.
Floods also raise bacterial exposure. A fistula or dialysis catheter is a direct route into the bloodstream, and a PD catheter a route into the abdomen, so they must stay covered from water. In people with reduced kidney function who are not yet on dialysis, dehydration from diarrhea causes acute kidney injury; metformin, which is cleared by the kidneys, then accumulates, inhibits mitochondrial oxygen use and allows lactic acid to build up into severe acidosis.

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