What are the ethical and legal issues involved in Renal Replacement Therapy (RRT) for patients with End-Stage Renal Disease (ESRD)?

Ethical and Legal Issues in Renal Replacement Therapy

The ethical and legal framework for RRT centers on patient autonomy through informed consent, equitable access to treatment modalities, and the right to refuse or withdraw from therapy, with KDIGO guidelines emphasizing that RRT decisions must align with patient goals of care and that conservative management is a legitimate option for those who decline dialysis or transplantation.

Patient Autonomy and Informed Decision-Making

Patients must receive comprehensive education about all RRT modalities before making treatment decisions, as this directly impacts concordance between chosen and actual therapy. 1

• The multidisciplinary team should provide access to education and counseling about different RRT modalities, transplant options, vascular access surgery, and ethical, psychological, and social care 1
• Patient decision aid tools (PDAs) significantly improve concordance between patient choice and definitive modality, with kappa values of 0.91-0.93 when properly implemented 2
• Patients who complete structured education programs change their minds significantly less often, even when starting treatment unplanned 2
• Free choice assisted by PDAs leads to approximately 50/50 distribution between peritoneal dialysis and hemodialysis, demonstrating genuine patient preference rather than provider bias 2

Right to Refuse or Withdraw Treatment

Conservative management without RRT is an ethically valid option that must be offered and supported with comprehensive palliative care programs. 1

• KDIGO explicitly states that RRT should be discontinued "when it is no longer consistent with the goals of care," establishing the ethical foundation for treatment withdrawal 1
• All CKD programs and care providers should offer conservative management as an option for patients who choose not to pursue RRT 1
• A palliative approach to ESRD is reasonable particularly for individuals with limited life expectancy, severe comorbid conditions, or who wish to avoid medical interventions 3
• For patients who decide against RRT or choose to discontinue dialysis, palliative care and hospice referral are indicated 4

Timing and Initiation Decisions

Dialysis initiation must be based on clinical symptoms and patient goals rather than arbitrary laboratory thresholds alone, avoiding premature initiation that may harm quality of life. 1

• KDIGO recommends considering the broader clinical context, presence of modifiable conditions, and trends of laboratory tests rather than single BUN and creatinine thresholds when deciding to start RRT 1
• Dialysis should be initiated when symptoms or signs attributable to kidney failure are present: serositis, acid-base or electrolyte abnormalities, pruritus, inability to control volume status or blood pressure, progressive deterioration in nutritional status, or cognitive impairment 1
• The interpretation of symptoms should be individualized with consideration of the expected benefit each patient may derive from starting dialysis 1
• Emergent RRT must be initiated immediately when life-threatening changes in fluid, electrolyte, and acid-base balance exist 1, 5, 6

Equitable Access and Resource Allocation

Timely referral to nephrology services is essential to ensure equitable access to all treatment modalities including transplantation, with referral recommended when kidney failure risk exceeds 10-20% within one year. 1

• Timely referral for planning RRT should occur in people with progressive CKD when the risk of kidney failure within 1 year is 10-20% or higher, as determined by validated risk prediction tools 1
• The aim is to avoid late referral, defined as referral to specialist services less than 1 year before start of RRT 1
• Transplantation is the treatment of choice for patients with ESRD, and referral should be offered to all candidates 4
• Living donor preemptive renal transplantation should be considered when GFR is <20 ml/min/1.73 m² with evidence of progressive and irreversible CKD over the preceding 6-12 months 1

Modality Selection and Patient Preference

The form of RRT should primarily be based on patient preference following individually tailored education, as there is no conclusive evidence that either dialysis modality is superior for mortality outcomes. 7, 8, 4

• Patient education is paramount in ESRD management, with the RRT modality based on patient preference subsequent to an individually tailored education program from specialist staff 7
• No differences in long-term mortality rates between peritoneal dialysis and hemodialysis have been demonstrated 4
• Important factors to consider include not only mortality and morbidity, but also quality of life, patient age and social circumstances, and the etiology of ESRD 8
• The education program needs to account for the patient's comorbidities and any contraindications to specific modalities of RRT 7

Vascular Access Preservation

For patients with stage III-V CKD at risk of requiring hemodialysis, peripheral vein preservation is an ethical imperative to ensure future treatment options. 3

• Because most patients with ESRD elect to receive hemodialysis, preservation of peripheral veins is important for those with stage III to V chronic kidney disease 3
• This requires educating patients and all healthcare providers about avoiding unnecessary venipuncture in potential dialysis access sites 3

Discontinuation of RRT

RRT discontinuation decisions must balance clinical indicators of kidney recovery against patient goals, with KDIGO establishing that continuation is not required when therapy no longer meets patient needs. 1

• RRT should be discontinued when it is no longer required, either because intrinsic kidney function has recovered to the point that it is adequate to meet patient needs, or because RRT is no longer consistent with the goals of care 1
• Urine output prior to discontinuation of RRT is the most commonly described and robust predictor of successful discontinuation, with sensitivity of 66.2% and specificity of 73.6% 1
• Patients discharged while still receiving RRT require frequent review of kidney function, with weekly assessment of pre-dialysis serum creatinine values and regular assessment of residual kidney function 6

Special Populations and Vulnerable Patients

Elderly patients, those with diabetes, and individuals with limited life expectancy require careful ethical consideration regarding whether RRT initiation aligns with their values and realistic outcomes. 8, 3

• Diabetic patients, the elderly, and patients with HIV infection or AIDS present complex issues regarding renal replacement therapy and outcomes 8
• Among certain subgroups of patients, the risk of death is higher than the risk of ESRD, and if planning for RRT is not properly targeted, the costs and harms might outstrip the benefits 1
• Motivated patients with available resources, regardless of ESRD cause, should be considered as candidates for home hemodialysis, which is associated with improved survival and quality of life 8

Legal Documentation and Shared Decision-Making

The decision to initiate dialysis is best made through shared decision-making with proper documentation of patient preferences and goals of care. 3

• Shared decision-making ensures that treatment decisions align with patient values and legal standards for informed consent 3
• Documentation should include discussion of all available modalities, risks and benefits, and patient's understanding and preferences 2