Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7178.217 (Published 23 January 1999) Cite this as: BMJ 1999;318:217All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Editor,
I agree with Chandna et.al (ref 1) that late referral is an important
factor in the survival of patients on dialysis. However, I am unaware of
their source of this information that NHS consensus statement recommends
nephrology
referrals be made at a serum creatinine concentration>135umol/l
(1.5mg/dl) in women and 180umol/l (2.0mg/dl) in men. I fear that his
practice would open
floodgate of referrals and the workload generated I imagine would be so
enormous that the British Renal Units under present conditions would be
unable to cope.
I am also concerned that of their 292 dialysis patients, 26 (9%)
admittedly high risk group patients spent 44% of their lives in hospital.
The costs of inpatient treatment for these high risk patients would be
substantially higher
than the average cost of £250 per day as quoted by the authors.
Dr Rasheed Ahmad
Consultant Renal Physician
Royal Liverpool University Hospital
Liverpool
L7 8XP
Reference:
1 Chandna SM, Schulz J, Lawrence C, Greenwood RN, Farrington K. Is
there a rationale for rationing chronic dialysis? A hospital based cohort
study of factors affecting survival and morbidity.BMJ 1999; 318 : 217.(23
January.)
Competing interests: No competing interests
Dear Editor
The study by Chandna et al does not fulfil the stated purpose of
their study (1). The study successfully shows the groups of patients
already receiving dialysis who could be expected to do poorly and this
might be used as a rationale for withdrawing treatment in this small group
of patients. The cost savings their unit would accrue are nonetheless
quite small (just 3.2% of their total chronic program). Even in their high
risk group five out of twenty six patients were long term survivors. This
is comparable to the effect of interferon therapy in hepatitis C in terms
of long term response and better than results for in vitro fertilisation
programs. One could argue that they should not therefore be refused
treatment either. Quality of life considerations would be important to
know about in this group since it may be these five patients had an
excellent quality of life as indeed may some of the other patients.
Their study however cannot be considered a basis for rationing access to
renal replacement. The authors do not report the characteristics or
reasons for refusal of patients referred to them for renal replacement.
Their assertion that the Wiltshire Health Authority recommendations may be
used as a starting point in deciding prioritisation is also not valid.
They agree that these are couched in general terms, although they are not
specified in their paper. Further they state that patients were assessed
on an individual basis with no formal criteria being used.
Their study does show that the criteria used to decide acceptance on to
their renal replacement program is clearly working for the patients who
are accepted. What the study does not tell us is whether the correct
criteria are being used for those refused renal replacement. It would be
interesting to know what happened to those refused replacement and on what
grounds this decision was made.
Yours sincerely
Dr T Farrant
Specialist Registrar Gastroenterology
Jersey General Hospital
Gloucester Street
St Helier
Jersey, Channel Islands
1. Chandna SM, Schulz J, Lawrence C, Greenwood RN, Farrington K. Is
there a rationale for rationing chronic dialysis? A hospital based cohort
study of factors affecting survival and morbidity. BMJ 1999; 318:217 -
223.
Competing interests: No competing interests
Author's reply to Dr Ahmad and Dr Farrant
The Editor,
BMJ.
Sir,
Dr Ahmed is correct to point out that there is no NHS consensus
recommending nephrology referrals. It was a typing error and should have
read NIH as was clear from the reference quoted.[1] Encouraging early
referral will undoubtedly mean more work in nephrology outpatients but
this may well be offset by reduced work, and costs, due to fewer unplanned
presentations for dialysis which at present account for 44% of all
patients entering the chronic dialysis programme.
He may be right in expecting higher than average in-patient costs of
the 26 high-risk patients. However it makes very little practical
difference since many of these patients did not live very long. In total
they had 428 inpatient days during the first 3 months and even if these
are costed at an average of £350.00 per day, the figure in table 3 will
change from 3.2% to 3.5%.
We do not agree with Dr Farrant that our study objectives were not
achieved. The study identified a cluster of factors affecting survival and
hospitalisation in dialysis patients and using these, defined a small high
-risk group with a very poor one-year survival. We suggested that the
methods used to define this group might be tested prospectively. We did
not advocate using these as basis for formal rationing. We do think our
findings might contribute to the understanding of a very complex decision
making process. Dr Farrant poses the same question which we did. Is 19%
one-year survival low enough to justify withholding dialysis for this high
-risk group? This is a value judgement which such a study cannot make but
perhaps it can begin to help lay some foundations.
Yours sincerely
Shahid M Chandna
Associate Specialist
Ken Farrington
Consultant Nephrologist
1. NIH consensus conference statement. Morbidity and mortality of
renal dialysis. Ann Intern Med 1994;121:62-70
Competing interests: No competing interests