Ethics of Dialysis in People with Advanced Kidney Disease Who Inject Drugs

Background: Barriers such as unstable housing, lack of insurance, and social stigma make it challenging to secure outpatient dialysis for people who inject drugs (PWID) with advanced kidney disease. We describe four cases from our center and propose a bioethical framework for guiding clinicians in dialysis planning. Methods: Cases were obtained through review of medical records from 2022-2024. Inclusion criteria were: PWID, chronic xylazine wounds, CKD stage 5 or end-stage kidney disease, and life-prolonging goals of care. We described their baseline characteristics, time of initial presentation (each presented for nonhealing leg wounds), management decisions regarding dialysis, and long-term outcomes. Results: See Image 1 Conclusion: These are challenging cases as there are no established guidelines for determining outpatient dialysis candidacy. Decisions are often driven by unfounded stereotypes which typically default to declaring the patient unfit. We propose evaluating patients through the lens of four bioethical principles: autonomy, beneficence, nonmaleficence, and justice. This strategy permits evaluation of the risks and benefits to the individual, system, and society. In each of the outlined cases, the patients’ goal is life prolongation (autonomy), and 3 have begun dialysis (beneficence). Nonmaleficence is often cited when discussing long-term dialysis candidacy, due to concern patients may inject into catheters, increase risk of infection, and hasten death. Two patients have tunneled catheters and have not used their catheters to inject drugs. Justice is the most nuanced of the principles, given the systemic barriers to placing high-risk patients in dialysis units and the psychosocial barriers to accessing appropriate dialysis care, as evidenced by the 120 hospital visits for these patients since time of identification. In summary, PWID with concomitant advanced kidney disease present a unique challenge. Patients and clinicians can implement a systematic framework with these four bioethics principles to evaluate outpatient dialysis candidacy.Results