To illustrate how these general conclusions might be resolved in practice, we consider the allocation of hemodialysis units in Syria, where seven years of armed conflict has led to hundreds of thousands of deaths and the displacement of approximately half the Syrian population. An underappreciated effect of the Syrian conflict has been the collapse of support for individuals receiving long-term clinical care, including patients with ESRD. We chose the example of ESRD because of its high cost, complex requirements of its provision, and imminent death when its treatment with renal replacement therapy is interrupted. Dialysis centers in areas such as Aleppo, Homs, and Idlib have been destroyed, looted, or occupied by armed groups .
In light of the above considerations of resource modalities, the risks of armed conflict, and culture, we offer the following principles for allocating hemodialysis sessions.
(1) Balancing safety and supply Hemodialysis should only be allocated when it is necessary to maintain patient outcomes. Given that replacement of supplies is far from guaranteed, and care at a facility risks healthcare workers and patients, the lowest possible frequency of hemodialysis cycles should be pursued, and the remaining supplies secured against future shortages. Even in resource-rich settings, reducing dialysis frequency is being considered as a safe and cost-effective approach under some conditions .
Urinary volume, as a proxy for residual renal function could be used as a guide to deciding which patient is a candidate for reduced dialysis frequency . We recommend longer dialysis duration of about 5–6 h in patients who end up receiving a sub-optimal dialysis frequency. The longer duration partially compensates for the reduced frequency, does not incur additional transportation cost or risk, and requires little additional dialysis supplies.
Where possible, alternative modalities or relocation should be used to decrease stress on remaining supplies. Peritoneal dialysis using available catheters and home made solutions has been used save lives in acute kidney injury in resource-limited settings . In the absence of hemodialysis supplies the same technique could be used in ESRD to buy time while waiting for new lines of supplies. If feasible, hemodialysis patients should be moved and housed in centers outside the conflict zone.
At a certain point the relationship between dose and frequency of dialysis, generally speaking, results in a sharp increase in risk for patients. This relationship is dependent on a patient’s remaining kidney function, reserve of other organs, and diet, but in general risk sharply increases if dialysis frequency falls below two sessions per week. Consider a recent comparison of outcomes between two dialysis facilities in Syria, one is in a besieged area and the other with access to supplies. One of the striking differences between the clinics was the frequency of dialysis: twice a week in the non-besieged facility and once a week in the besieged. After one year almost a half of the patients in the first unit died compared to 21% in the latter .
While there were surely other factors distinguishing the two facilities, the divergence of clinical outcomes based on a change in frequency of dialysis highlights the need for care providers to carefully select the rate of dialysis to balance patient safety against continuing supply. The increased risk to patients is not an in principle reason to refrain from reducing the frequency of dialysis. Increasing dialysis frequency and ultimately running out of supplies for all patients also entails risk, as does maintaining frequency while reducing the set of patients who receive care. Caregivers should strive to maintain sufficient quality of life for as wide a group of patients as possible.
(2) Priority setting Patients with ESRD are particularly vulnerable during armed conflicts: their expected comorbidities and lack of access to food and water render them in dire need of care. However, standard allocation principles (Table 1) are not sufficient in the face of this need. A lottery could be disastrous, as the distribution of already scarce dialysis resources would arguably lead to significant mortality in depriving patients of dialysis appropriate their prognosis, without necessarily adding value to those who do receive dialysis beyond their necessary courses.
We can envisage some kind of de facto first come, first served principle applying alongside others, in cases where uncertainty about the ability to travel make scheduling patients very difficult. That is, clinicians may want to set patients on courses of hemodialysis in cases where there is no guarantee that another patient will show up at the right time (say, because conditions of conflict have changed). We strongly discourage clinicians for adopting first come, first serve, however, as a principle for ex ante allocating resources to patients undergoing hemodialysis.
A tension arises between favoring the sickest, and maximizing life years for younger patients. On the face of it, emergencies such as severe hyperkalemia and volume overload should be given priority including additional dialysis sessions and even hospitalization with emergency dialysis. Relying solely on this principle, however, is not sufficient because it will eventually lead to a patient’s death of other uremic manifestations. Moreover, elderly patients tend to have increased co-morbidities and performing dialysis may provide little or no benefit. While the concept of palliative or conservative care in elderly patients with CKD is discussed as a futility question , its implementation has justice implications in the context of the Syrian conflict because it reduces spending of insecure resources.
In cases where supplies are not sufficient to ensure patient outcomes, hemodialysis should be prioritized according to
A patient’s capacity to contribute to the care of others or provision of critical services to civilians during the conflict;
The patient’s overall prognosis;
A patient’s capacity to endure suboptimal clinical outcomes due to shortages.
That is, in conditions of scarce and insecure medical resources, those who can contribute to maintaining community support during the conflict-and potentially to later reconstruction efforts—should be prioritized. Then, we should allocate to those with the best overall prognosis. Finally, we should allocate to those whose suffering would be most acute were they to forgo dialysis.
The rationale for this is as follows. In conflict zones, maintaining essential services is vital not just to ESRD patients, but to everyone—utilitarian and social usefulness (itself promoting utility) principles outweigh other principles in a general sense, given the protracted nature of the conflict. Those who are both most likely to survive and contribute to caregiving in the wider community ought to be prioritized—in particular, those who care for other vulnerable individuals, such as young children or injured civilians, should be prioritized. Finally, those in the worst condition should be given care in order to relieve their suffering.
(3) Alternative modalities Peritoneal dialysis as an initial form of renal replacement therapy offers the advantage of eliminating the need for patient transportation in dangerous conditions and is less technologically demanding: there is no need for electricity when peritoneal dialysis is performed manually. The penetration of this modality in the management of ESRD patients in many developing countries, including Syria, has been low. One of the main reasons for this phenomenon is that, compared to developed countries, peritoneal dialysis in some developing countries is more expensive than hemodialysis .
Conservative non-dialytic management of elderly patients with advanced chronic kidney disease is an option that has been increasingly applied. The care is mostly palliative and patients may survive for months while clinically uremic due to some residual renal function .
(4) Palliative care The ultimate consequence of allocation paradigms, in any situation, is that a patient will inevitably be denied care. In these cases palliation for pain or other effects of forgoing dialysis should be, where possible, reserved for those who are most likely to be denied hemodialysis. Details of aspects of palliative renal care are beyond the scope of this work, but have been covered elsewhere .
Local religious figures ought to, where possible, be sourced to provide compassionate care—while there is some evidence that Islamic bioethical principles are consonant with standard Western accounts of ethical allocation principles, their framing may differ, and religious figures may be best placed to facilitate discussions about the allocation and timing of hemodialysis .