key: cord-1040645-r3y41lfg
authors: Jain, Gaurav
title: Rationing of Medical Supplies Including Ventilators in Patients With Kidney Disease
date: 2020-04-30
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.04.029
sha: 437af60d37608c04ec7767783ffe13f198ec07f4
doc_id: 1040645
cord_uid: r3y41lfg

nan

To the Editor: The COVID-19 pandemic has altered medical practice in all disciplines and subspecialties. In nephrology such alterations involve the following issues: the availability of staff and resources to perform dialysis in suspected or confirmed COVID patients; infection prevention practices especially in the realm of social isolation; delay in the placement of dialysis vascular accesses and peritoneal dialysis catheter; and continued access to care for patients with established chronic kidney disease (CKD) and immunosuppressed renal transplant patients. To meet these challenges, prompt and judicious responses have occurred, including by the American Society of Nephrology (ASN) and the guidelines this society issued, by dialysis providers, and by the rapid incorporation of telenephrology in clinical practice. Such actions are works-in-progress that are, and will be, constantly being improved and refined, and, indeed, have been successfully implemented at many places. 1 A controversial issue that has gained considerable attention is the rationing of critical care services especially mechanical ventilators, with exclusion of patients with some medical conditions including CKD and end stage renal disease (ESRD). 2, 3 This needs to be carefully analyzed and fairly resolved, as it can introduce disparity in care based on categorical and seemingly arbitrary exclusions, rather than a reasoned and ethical strategy to prioritize care.

While it is essential to have an emergency preparedness plan in the event of a shortage of ventilators, such a plan should not be based on excluding health conditions merely on the basis of their apparent poor long-term prognosis, as has long been considered for conditions such as CKD and ESRD. The mortality of patients with ESRD and CKD continues to decline in the past decade, and the employment rates for these patients are improving. 4,5 A young patient with ESRD secondary to polycystic kidney disease and no other comorbidities has a much better long-term prognosis than a 73 y/o diabetic patient with ESRD and advanced heart failure; categorical exclusion on the basis of a blanket diagnosis of ESRD does not account for a stark difference in the long-term prognosis for these two patients. National organizations such as the National Kidney Foundation and many nephrology practices have requested considering a decision-making protocol based on the unique medical circumstances of each patient, rather than exclusion based on a pre-existing condition like kidney disease. 6, 7 Recent work from the University of Pittsburgh Medical Center lays a thoughtful and helpful framework in addressing the ethical and logistic challenges in such a health care crisis. 8, 9 The goal of the allocation system in such situations needs to be twofold. The first is the "greatest good for the greater number", meaning that resources are utilized in a way that they benefit the majority, especially when resources are limited. The second is the need to ensure that every patient gets meaningful access to care based on their current clinical condition, and is not denied care based on an arbitrary criterion such as a disease diagnosis. This will only be possible if there is a rigorous system in place to triage patients, based on an individual clinical assessment and a scoring system which incorporates several factors. As recently delineated by White and Lo, 8 salient considerations in the decision-making process include, among others, the following: 1. Short term prognosis, based on a validated objective measure of probability of survival to discharge (such as the Sequential Organ Failure Assessment or SOFA score); 2. Long term prognosis, to determine patients who have a limited life expectancy despite surviving the hospitalization and the ICU stay; 3. Prioritizing groups vital to the public health response, in the management of the acutely ill, and in protecting lives; 4. Prioritizing patients who are younger so as to afford them an experience of life that is more extended rather than unexpectedly curtailed and thus one with more meaning. It is crucial to reassess available resources at frequent intervals, to ensure reallocation of the resources based on availability and the burden of disease. Lastly, for patients who receive critical care services and ventilators, timely and repeated reassessments after a therapeutic trial duration will help make informed and prudent decisions about continuing the trial, or utilizing these resources for other sick patients.

In these unprecedented times the medical community, providers, public health policy makers, ethicists, and the public are in a unique position to determine practices and guidelines pertaining to emergency preparedness and the provision of care with limited resources. In this regard, we believe that CKD/ESRD should not be blanket exclusionary conditions as regards the provision of critical care services including ventilator support for two principal reasons. First, for these conditions, mortality rates have decreased and the quality of life improved in recent years. And second, with either condition, outcomes are vastly different depending upon the individual patient, their co-morbidities and the specific cause of either CKD or ESRD.

Gaurav Jain, MD University of Alabama Birmingham, Alabama

Mitigating risk of COVID-19 in dialysis facilities

Henry Ford Health officials confirm letter outlining life and death protocols for COVID-19

Coronavirus Cases Could Force Rationing Decisions Similar to Those Made in Italy, China. Ariana Eunjung Cha. Washington Post

USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases

Employment among patients on dialysis. CJASN

NKF Urges America's Hospitals and Health Systems to Not Implement Policies to Deprive Kidney Patients from Lifesaving Interventions During COVID-19. National Kidney Foundation

NKF: Patients with ESKD may be getting low priority if ventilators need to be rationed Mark Neuman Nephrology News and Issues

A framework for rationing ventilators and critical care beds during the covid-19 pandemic

A model hospital policy for allocating scarce critical care resources