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.
Rapid Response:
Renal replacement therapy
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