[Ethical problems posed by treatments of terminal chronic uremia]

Among about 650,000 patients treated worldwide by maintenance dialysis methods for end-stage renal failure, approximately 85% undergo hemodialysis and 15% peritoneal dialysis. For the 25,000 patients thus treated in France in 1991, expenditures ranged between 8 to 10 billion French Francs. These socio-economic factors necessarily generate a conflict between resource allotment and medical ethics. One of the questionable options requiring decisions at the onset of treatment is the patient's age. An age-based patient selection is actually unfounded. In a recent French cohort of 213 patients treated exclusively with peritoneal dialysis and whose mean age at start of treatment was 79 +/- 4 years, the survival rate at three years was 45%. Patient selection for either a given mode or abstention from treatment should be based on a careful analysis of comorbidities associated with end stage renal failure. This selection process is sometimes very difficult to achieve successfully since some patients initially considered as being in an irreversible condition may greatly improve their status after a few weeks or months of dialysis. The dilemma is to decide whether or not initiate dialysis or to "give the patient a chance", looking forward to discontinue the treatment if no significant improvement is obtained. A successful kidney transplantation is widely accepted as the best treatment for end-stage renal failure. Unfortunately the number of organ donors (mainly cadaveric) remains insufficient to meet the demand, again raising a difficult issue of patient selection. In the future, further complex problems will emerge with the introduction of xenotransplantation. These and many other issues, including availability of treatments in developing countries have been and will continue to be subjects for debate among nephrologists, the medical community at large and also health care authorities as well as equipment manufacturers, with the ultimate aim of providing low-cost treatment for all the patients in the world who require a long-term life saving therapy.