Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity

BMJ 1999;318:217-223 ( 23 January )

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Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity

Shahid M Chandna, associate specialist, ^a Joerg Schulz, senior lecturer, ^b Christopher Lawrence, medical student, ^a Roger N Greenwood, consultant, ^a Ken Farrington, consultant. ^a

^a Department of Nephrology, Lister Hospital, Stevenage SG1 4AB, ^b Department of Psychology, University of Hertfordshire, Hatfield AL10 9AB

Correspondence to: Dr Chandna shahid.chandna{at}lister.org.uk

Objectives: To determine factors influencing survivaland need for hospitalisation in patients needing dialysis, andto define the potential basis for rationing access to renal replacementtherapy.
Design: Hospital based cohort study of all patientsstarting dialysis over a 4 year recruitment period (follow up15-63 months). Groups were defined on the basis of age, comorbidity,functional status, and whether dialysis initiation was plannedorunplanned.
Setting: Renal unit in a district general hospital,which acts as the main renal referral centre for four other suchhospitals and serves a population of about 1.15 millionpeople.
Subjects: 292 patients, mean age 61.3 years (18-92 years,SD 15.8), of whom 193 (66%) were male, and 59 (20%) were patientswith diabetes. Dialysis initiation was planned in 163 (56%) patientsand unplanned in 129 (44%).
Main outcome measures: Overall survival, 1 year survival, and hospitalisationrate.
Results: Factors affecting survival in the Cox's proportionalhazard model were Karnofsky performance score at presentation(hazard ratio 0.979, 95% confidence interval 0.972 to 0.986),comorbidity severity score (1.240, 1.131 to 1.340), age (1.036,1.018 to 1.054), and myeloma (2.15, 1.140 to 4.042). The Karnofskyperformance score used 3 months before presentation was significant(0.970, 0.956 to 0.981), as was unplanned presentation in thismodel (1.796, 1.233 to 2.617). Using these factors, a high riskgroup of 26 patients was defined, with 19.2% 1 year survival.Denying dialysis to this group would save 3.2% of the total costof the chronic programme but would sacrifice five long term survivors.Less rigorous definition of the high risk group would save moremoney but lose more long termsurvivors.
Conclusions: Severity of comorbid conditions and functionalcapacity are more important than age in predicting survival andmorbidity of patients on dialysis. Late referral for dialysisaffects survival adversely. Denial of dialysis to patients inan extremely high risk group, defined by a new stratificationbased on logistic regression, would be of debatablebenefit.

Key messages

Functional status (assessed by Karnofsky performance score), severity of comorbid conditions, and age affect survival on dialysis
Late referral is an important factor in poor survival and high costs
Rationing of dialysis on the basis of age alone is unjustified
A high risk group can be defined by logistic regression analysis using functional status, severity of comorbid conditions, and age
Limited cost savings can be generated by denying access to dialysis to this high risk group, but long term survivors are sacrificed

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Rapid Responses:

Read all Rapid Responses

Rationing Chronic Dialysis: Rasheed Ahmad
bmj.com, 27 Jan 1999 [Full text]
Renal replacement therapy: T Farrant
bmj.com, 27 Jan 1999 [Full text]
Author's reply to Dr Ahmad and Dr Farrant: Shahid M Chandna
bmj.com, 4 Feb 1999 [Full text]