To the Editor,
I sincerely appreciate the article by Silberzweig et al.,1 which addresses the potential effect of health care resource rationing on patients with CKD. The authors discuss the ethical principles underpinning the scarce resource allocation systems considered in the throes of the coronavirus disease 2019 pandemic. They specifically call attention to the use of strict exclusion criteria, including ESKD, as a reason to deny a patient other life-saving treatments, such as mechanical ventilation, in the setting of crisis standards of care.1
The authors recommend that in the event that all contingency plans have been exhausted, tools such as the Sequential Organ Failure Assessment (SOFA) score should be used to determine eligibility for scarce resources.1 Although the SOFA score provides an objective estimate of mortality and is therefore a step forward from exclusion criteria, I feel it is important to point out its flaws in patients with CKD and ESKD.
The SOFA score assigns points on the basis of the absolute creatinine value at a single point in time. Because the goal of the scoring system is to assess organ dysfunction resulting from severe illness, the change in creatinine would be a much more useful metric. It is known that AKI carries an increased risk of mortality in critically ill patients,2 but the presence of CKD may modify this association. Critically ill patients with preexisting CKD who develop AKI have lower mortality than those without.3 The Acute Physiology and Chronic Health Evaluation (APACHE) score differentiates between AKI and CKD in assigning points and may be more equitable. However, because the APACHE score includes electrolyte abnormalities, its performance among patients with ESKD is moderate at best, with a tendency to overestimate mortality.4
Illness severity scores were never intended to be interpreted as a snapshot or used to allocate scarce resources. However, as noted by the authors, objective and quantitative metrics are integral to ethical triage decision making. Therefore, to provide just treatment for our patient population, we must recognize the biases in these scores and investigate better methods of assessing mortality.
Disclosures
The author has nothing to disclose.
Funding
None.
Footnotes
Published online ahead of print. Publication date available at www.jasn.org.
References
- 1.Silberzweig J, Ikizler TA, Kramer H, Palevsky PM, Vassalotti J, Kliger AS: Rationing scarce resources: The potential impact of COVID-19 on patients with chronic kidney disease. J Am Soc Nephrol 31: 1926–1928, 2020 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.de Mendonça A, Vincent J-L, Suter PM, Moreno R, Dearden NM, Antonelli M, et al. : Acute renal failure in the ICU: Risk factors and outcome evaluated by the SOFA score. Intensive Care Med 26: 915–921, 2000. [DOI] [PubMed] [Google Scholar]
- 3.Khosla N, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini E, et al. ; Program to Improve Care in Acute Renal Disease (PICARD) : Preexisting chronic kidney disease: A potential for improved outcomes from acute kidney injury. Clin J Am Soc Nephrol 4: 1914–1919, 2009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Arulkumaran N, Annear NMP, Singer M: Patients with end-stage renal disease admitted to the intensive care unit: Systematic review. Br J Anaesth 110: 13–20, 2013. [DOI] [PubMed] [Google Scholar]