Moosa Mohammed Rafique, Maree Jonathan David, Chirehwa Maxwell T, Benatar Solomon R
Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
Renal Unit, Tygerberg Academic Hospital, Cape Town, South Africa.
PLoS One. 2016 Oct 4;11(10):e0164201. doi: 10.1371/journal.pone.0164201. eCollection 2016.
Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the 'Accountability for Reasonableness' (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.
由于患者数量众多以及治疗终末期肾病的反复成本高昂，普及肾脏替代疗法超出了大多数低收入和中等收入国家的经济承受能力。在那些获取治疗机会有限的国家，不存在能够优化利用稀缺透析设施的系统。我们之前报告称，使用国家指南来选择接受肾脏替代疗法的患者会导致分配偏差。我们与相关利益攸关方合作，采用“合理性问责”（程序公平）框架重新设计了选择指南，并以一种新颖的方式将这些指南应用于以独特的层级方式对患者进行分类和排序。这些指南主要基于患者是否适合移植。我们研究了修订后的指南是否提高了透析资源分配的公平性。这是一项对1101名终末期肾衰竭患者的描述性研究，这些患者前往一个中等收入国家的三级肾脏科就诊，在七年时间里接受了透析治疗评估。评估委员会使用基于合理性问责的指南将患者分配到三个评估组之一。第1类患者可确保接受肾脏替代疗法，第3类患者接受姑息治疗，第2类患者在资源允许的情况下接受治疗。在所有接受评估的终末期肾病患者中，只有25.2%被接受进行肾脏替代治疗。大多数患者（48%）被分配到第2类。在134名第1类患者中，98%被接受治疗，而438名（99.5%）第3类患者被排除。与接受姑息治疗的患者相比，接受透析治疗的患者年龄几乎小10岁，有工作，已婚并有子女，且非糖尿病患者。与我们之前的选择过程相比，我们目前基于程序公平的优先级设定方法可以说导致了更公平的治疗分配，但更重要的是，这是一个在道德、法律和伦理上更具合理性的模式。
