This Month in AJKD

Article Outline

• Epoetin Dosing in Dialysis Facilities: The Discussion Continues
• Fistulas First, Catheters Last
• Anticoagulation in Hemodialysis Patients With Atrial Fibrillation

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Epoetin Dosing in Dialysis Facilities: The Discussion Continues 

See Weiner and Levey, pages 349-353; Kasiske, pages 354-357; Macdougall, pages 358-361; Cohen and Neumann, pages 362-365; and Lazarus and Hakim, pages 366-370.

The recent article by Thamer et al, “Dialysis Facility Ownership and Epoetin Dosing in Patients Receiving Hemodialysis” from the April 2007 issue of Journal of the American Medical Association has generated much discussion, particularly in light of recent studies on the effects of high hemoglobin levels and epoetin dosing. In this issue, the AJKD Editors solicited editorials from experts with diverse perspectives to respond to the article. In their introductory editorial, Drs Weiner and Levey review the history of epoetin utilization and reimbursement in the US and highlight key findings from the Thamer article.The following two editorials reflect the perspectives of physicians; Dr Kasiske presents the perspective of a US dialysis physician and Dr Macdougall offers an international view from the capitated system of the United Kingdom. Next, Drs Cohen and Neumann, both medical economists, discuss the article from the payer perspective and analyze the influence of Medicare reimbursement strategies on EPO use. In the final editorial, Drs Lazarus and Hakim of Fresenius Medical Care present the perspective of a large for-profit dialysis provider.

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• Figure reproduced with permission. Figure 2A from Thamer et al: Dialysis facility ownership and epoetin dosing in patients receiving hemodialysis. JAMA 297:1671, 2007

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Fistulas First, Catheters Last 

See Lacson et al, pages 379-395.

The Centers for Medicare and Medicaid Service’s “Fistula First” initiative, which recently reached its goal of 40% fistula prevalence in hemodialysis patients, may have inadvertently increased the use of catheters as well. In this issue, Lacson et al point out 3 major drawbacks to the initiative (absent or late placement of fistula in patients initiating dialysis, delay or failure of fistula maturation, and failure to maintain long term fistula patency), that may have led to increased use of catheters. In response to this phenomenon, Lacson et al propose a “Fistula First, Catheters Last” initiative, in which more attention is paid to timely removal of incumbent catheters and avoidance of catheter placement.

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Anticoagulation in Hemodialysis Patients With Atrial Fibrillation 

See Quinn et al, pages 421-432; Elliott et al, pages 433-440; and Abbott et al, pages 345-348.

Approximately 14% of hemodialysis patients have atrial fibrillation, and this group appears to be at increased risk of both thromboembolic complications and bleeding. The role of warfarin and aspirin therapy in preventing strokes in these patients is relatively unknown, as hemodialysis patients are often excluded from trials studying these therapies. In this issue, Quinn et al perform a cost-utility analysis of 3 treatment strategies (warfarin, aspirin, and no therapy) to determine which is the most cost-effective. They find that aspirin and warfarin both prolong survival compared to no treatment (0.06 and 0.15 quality-adjusted life-years [QALYs], respectively). Aspirin is associated with an incremental cost-effectiveness ratio of $82,100/QALY and warfarin provides additional benefits at a cost of $88,400 for each QALY gained relative to aspirin. At a threshold of $100,000/QALY, the probabilities that no treatment, warfarin, or aspirin is the most efficient therapy were 20%, 58%, and 23%, respectively. The authors conclude that while further study is required to determine the efficacy of warfarin, it appears to be the optimal therapy. In a related article, Elliott et al examine the bleeding risk associated with warfarin treatment in hemodialysis patients. In a systematic review of observational studies and randomized controlled trials, they find that hemodialysis patients taking warfarin have at least double the risk of major bleeding episodes as compared to those receiving either no warfarin or subcutaneous heparin. An editorial by Abbott et al comments on the decision-analysis approach of the Quinn et al article and further examines the complex issues surrounding the use of anticoagulants in this population.

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