Balancing the Needs of Acute and Maintenance Dialysis Patients during the COVID-19 Pandemic: A Proposed Ethical Framework for Dialysis Allocation.

The COVID-19 pandemic continues to strain health care systems and drive shortages in medical supplies and equipment around the world. Resource allocation in times of scarcity requires transparent, ethical frameworks to optimize decision making and reduce health care worker and patient distress. The complexity of allocating dialysis resources for both patients receiving acute and maintenance dialysis has not previously been addressed. Using a rapid, collaborative, and iterative process, BC Renal, a provincial network in Canada, engaged patients, doctors, ethicists, administrators, and nurses to develop a framework for addressing system capacity, communication challenges, and allocation decisions. The guiding ethical principles that underpin this framework are (1) maximizing benefits, (2) treating people fairly, (3) prioritizing the worst-off individuals, and (4) procedural justice. Algorithms to support resource allocation and triage of patients were tested using simulations, and the final framework was reviewed and endorsed by members of the provincial nephrology community. The unique aspects of this allocation framework are the consideration of two diverse patient groups who require dialysis (acute and maintenance), and the application of two allocation criteria (urgency and prognosis) to each group in a sequential matrix. We acknowledge the context of the Canadian health care system, and a universal payer in which this framework was developed. The intention is to promote fair decision making and to maintain an equitable reallocation of limited resources for a complex problem during a pandemic.

External validation and clinical utility of a prediction model for 6-month mortality in patients undergoing hemodialysis for end-stage kidney disease.

BACKGROUND: End-stage kidney disease is associated with poor prognosis. Health care professionals must be prepared to address end-of-life issues and identify those at high risk for dying. A 6-month mortality prediction model for patients on dialysis derived in the United States is used but has not been externally validated. AIM: We aimed to assess the external validity and clinical utility in an independent cohort in Canada. DESIGN: We examined the performance of the published 6-month mortality prediction model, using discrimination, calibration, and decision curve analyses. SETTING/PARTICIPANTS: Data were derived from a cohort of 374 prevalent dialysis patients in two regions of British Columbia, Canada, which included serum albumin, age, peripheral vascular disease, dementia, and answers to the "the surprise question" ("Would I be surprised if this patient died within the next year?"). RESULTS: The observed mortality in the validation cohort was 11.5% at 6 months. The prediction model had reasonable discrimination (c-stat = 0.70) but poor calibration (calibration-in-the-large = -0.53 (95% confidence interval: -0.88, -0.18); calibration slope = 0.57 (95% confidence interval: 0.31, 0.83)) in our data. Decision curve analysis showed the model only has added value in guiding clinical decision in a small range of threshold probabilities: 8%-20%. CONCLUSION: Despite reasonable discrimination, the prediction model has poor calibration in this external study cohort; thus, it may have limited clinical utility in settings outside of where it was derived. Decision curve analysis clarifies limitations in clinical utility not apparent by receiver operating characteristic curve analysis. This study highlights the importance of external validation of prediction models prior to routine use in clinical practice.

A Survey of Canadian Nephrologists Assessing Prognostication in End-Stage Renal Disease.

BACKGROUND: Patients with end-stage renal disease (ESRD) frequently have a relatively poor prognosis with complex care needs that depend on prognosis. While many means of assessing prognosis are available, little is known about how Canadian nephrologists predict prognosis, whether they routinely share prognostic information with their patients, and how this information guides management. OBJECTIVE: To guide improvements in the management of patients with ESRD, we aimed to better understand how Canadian nephrologists consider prognosis during routine care. DESIGN AND METHODS: A web-based multiple choice survey was designed, and administered to adult nephrologists in Canada through the e-mail list of the Canadian Society of Nephrology. The survey asked the respondents about their routine practice of estimating survival and the perceived importance of prognostic practices and tools in patients with ESRD. Descriptive statistics were used in analyzing the responses. RESULTS: Less than half of the respondents indicated they always or often make an explicit attempt to estimate and/or discuss survival with ESRD patients not on dialysis, and 25% reported they do so always or often with patients on dialysis. Survival estimation is most frequently based on clinical gestalt. Respondents endorse a wide range of issues that may be influenced by prognosis, including advance care planning, transplant referral, choice of dialysis access, medication management, and consideration of conservative care. LIMITATIONS: This is a Canadian sample of self-reported behavior, which was not validated, and may be less generalizable to non-Canadian health care jurisdictions. CONCLUSIONS: In conclusion, prognostication of patients with ESRD is an important issue for nephrologists and impacts management in fairly sophisticated ways. Information sharing on prognosis may be suboptimal.

CONTEXTE: En règle générale, le pronostic des patients atteints d'insuffisance rénale terminale (IRT) est plutôt sombre et implique des besoins complexes en matière de soins. Bien qu'il existe diverses approches, on en sait peu sur la façon dont les néphrologues canadiens s'y prennent réellement pour établir le pronostic de leurs patients, et on ignore, premièrement, si l'information pronostique est systématiquement communiquée au patient et deuxièmement, comment cette information oriente la prise en charge du patient. OBJECTIFS DE L'ÉTUDE: Nous avons voulu mieux comprendre la manière dont les néphrologues canadiens tiennent compte du pronostic dans les soins aux patients afin d'éclairer les avancées dans la prise en charge des patients atteints d'IRT. CONCEPTION DE L'ÉTUDE ET MÉTHODOLOGIE: On a envoyé par courriel, un sondage Web à choix multiples à des néphrologues canadiens figurant sur la liste d'envoi de la Société canadienne de néphrologie. Le sondage interrogeait les répondants sur leur pratique habituelle d'évaluation de la durée de survie et sur leur perception de l'importance des outils et des pratiques pronostiques chez les patients atteints d'IRT. On a effectué une analyse statistique descriptive des réponses reçues. RÉSULTATS: Moins de la moitié des répondants a indiqué faire systématiquement ou souvent une tentative claire d'estimer la durée de survie ou d'en discuter avec le patient atteints d'IRT non dialysé, alors que seulement 25% le font dans le cas d'un patients dialysé. L'estimation de la durée de survie est le plus fréquemment basée sur une gestalt clinique. Les répondants rapportent un large éventail de questions pouvant être influencé par le pronostic, notamment la planification préalable des soins, la consultation en vue d'une transplantation, le choix de l'accès pour la dialyse, la gestion de la médication et la prise en considération d'un traitement conservateur. LIMITES DE L'ÉTUDE: Il s'agit d'un échantillon canadien non validé dont le comportement est autodéclaré et par conséquent, il pourrait ne pas correspondre à des systèmes de soins de santé à l'extérieur du Canada. CONCLUSIONS: L'établissement d'un pronostic chez les patients atteints d'IRT est un enjeu majeur dans la pratique des néphrologues canadiens et entraîne des répercussions relativement pointues sur la prise en charge du patient. La transmission de renseignements pronostiques pourrait ne pas être optimale.

Bilateral sequential adult cochlear implantation: who should receive priority in the context of a constrained health care system?

Resource allocation decisions have become increasingly necessary as the cost of health care habitually increases. Bilateral (second side) adult cochlear implantation (CI) is an example of a novel technology with accruing evidence of benefit, yet expense has limited universal employ. Currently at our centers, bilateral implantation is only provided under research protocol. In this article, we discuss the need for a principled approach concerning the distribution of a second device, both during this period of investigation and if ultimately an insured service. Allocation strategies, while extensively addressed in some arenas, have yet to be developed for second-side sequential adult CI. We advocate that physicians must assume an explicit role when both caring for individual patients as well as administering health care programs. We review social justice theories that inform resource allocation macrodecisions, and include a defence of age-based considerations. Our approach to patient selection for adult second-side CI sequentially considers clinical criteria (directly addressed in the article), a willingness to participate in rigorous research, and a 65 year cut-off. Ultimately, we employ random blinded selection for allocating bilateral CI among the remaining similarly situated individuals. This approach functions impartially and in a manner that is transparent for both patient and physician.

TTP/HUS: observational studies generate hypotheses that lead to randomized controlled trials.

Thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) is a disease syndrome, and its history exemplifies how small observational studies lead to hypotheses that spawn randomized control trials (RCTs). Moschowitz's original case report coupled with the case findings of Bukowski and Byrne led to the RCT of Rock and the Canadian Apheresis Group that proved plasma exchange was superior to plasma infusion for the treatment of adults with TTP/HUS. Our single case report of continuous plasma exchange coupled with the observations about the pathogenic role of von Willebrand multimer protease of Tsai and Furlan strengthened by a 25-year observational study of plasma exchange treatment for TTP/HUS has led to a proposal to initiate a new RCT.

TTP/HUS and prognosis: the syndrome and the disease(s).

Patients presenting with the syndrome of microangiopathic hemolysis and thrombocytopenia, without Shiga toxin-associated colitis, have thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS). Prognosis for TTP/HUS has changed over time from a fatal disorder associated with the classic pentad to a syndrome associated with 80% survival in the plasma exchange era. A growing number of mechanisms, including but not exclusive to severe ADAMTS13 deficiency, are now understood to result in this syndrome, and the prognosis of patients with TTP/HUS is related to many additional factors. This update on prognosis explores recent registry data studying both acquired idiopathic and also familial or recurrent forms of TTP/HUS, to delineate how mortality varies by underlying disease mechanism. This paper also explores the association between mortality and clinical presenting features, as well as whether the case is a primary or relapsed presentation. Recent data support an understanding of TTP/HUS as a heterogeneous syndrome with variable mortality, and with specific subgroups demonstrating an excellent outcome.

Treating TTP/HUS with plasma exchange: a single centre's 25-year experience.

Thrombotic thrombocytopenic purpura/Haemolytic uremic syndrome (TTP/HUS) is a thrombotic microangiopathy with a 6-month mortality rate of 16-29%. The present study described the clinical features, treatment regime and 6-month all-cause mortality rate of TTP/HUS patients at the London Health Sciences Centre (LHSC), Canada. Data for this retrospective cohort study were obtained from inpatient and outpatient records for all patients referred for plasma exchange therapy at LHSC, Canada between 1981 and 2006. Patients (n = 110) were categorized as: idiopathic primary (38%) or relapsed (16%), and secondary responsive (30%) or non-responsive (16%). Mortality data were available for all but three patients. The all-cause 6-month mortality rate was 19% overall and was 12% and 26% among idiopathic and secondary TTP/HUS patients, respectively. No mortality events occurred among the 17 idiopathic patients who relapsed. Relapsed patients had the least severe presenting characteristics, the fastest response time, and experienced significant improvement in the severity of clinical features between the first and final presentation. These findings suggest an excellent outcome for relapsed TTP/HUS patients. Patient education, surveillance, and aggressive plasma exchange therapy are hypothesized to improve the likelihood of survival: these hypotheses should be tested in a randomized controlled trial.