At the time, the regional health authority kidney programs were collectively delivering regular dialysis services to over 3,500 patients with chronic kidney disease across British Columbia. But care teams would face difficult ethical dilemmas if COVID patients experiencing acute kidney injury also needed access to dialysis machines and services, which are a limited resource.
Sarah Thomas, BC Renal project manager, was a key member of the team who helped develop the novel framework.
“Seeing what the rest of the world was going through and how they were concerned about having enough dialysis resources, we knew that we needed to come together as a kidney community to create guidance for our teams,” says Thomas.
A working group of people with diverse perspectives and expertise was quickly formed, and included professionals ranging from nephrologists to ethicists. Patients played a critical role, informing the group on what they consider to be important and fair considerations if their access to dialysis needed to be altered – or even reduced in frequency – during the pandemic. Patient partners emphasized the need for clear communication throughout the pandemic, and ideally before any changes to dialysis are implemented.
Along with developing a communication plan, the working group set out to create an algorithm that can be applied to all kidney patients – chronic and acute – who are awaiting dialysis, identifying those most in need of immediate treatment. It is based on the ethical principles of utility, efficiency and equity, whereby those with the greatest need and the greatest likelihood of benefit are prioritized for dialysis.
The algorithm estimates acute prognosis using a scoring system based on two combined approaches. The first is Sequential Organ Failure Assessment score, which is used to estimate the acute prognosis of patients. The second is the Charlson Comorbidity Index, which is useful for estimating long-term prognosis. By combining these, the resulting algorithm helps identify kidney patients who need dialysis urgently, and those who can wait a couple of days.
Thomas says that she is not aware of any similar algorithm that exists. She hopes that the new framework will support care teams, in BC and beyond, with an organized system for allocating health resources if they hit crisis operations.
The team worked long hours to create the framework, but there was much enthusiasm and drive behind their work.
“Just watching the group come together to build this algorithm and this framework was quite remarkable,” says Thomas. “Everyone was worried, everyone was tired. No one knew where COVID was going – but the dedication this group put into this was really a joy to be a part of, I must say.”
Especially among the working group, she wants to thank the patient partners who provided their lived experience.
“It made this project real and helped us stay focused on what really matters,” says Thomas.