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American Journal of Kidney Diseases

Regarding Early Initiation of Dialysis

      To the Editor:
      In the article by Harris et al
      • Harris A.
      • Cooper B.A.
      • Li J.J.
      • et al.
      Cost-effectiveness of initiating dialysis early: a randomized controlled trial.
      and the accompanying editorial by Manns and Quinn,
      • Manns B.J.
      • Quinn R.R.
      Early dialysis of no benefit to the patient or the health care system.
      there is no mention of the financial motivation to start dialysis therapy early. In the United States, partial ownership of dialysis centers through joint ventures is common. There is a distinct financial benefit to “keep the center full” and place patients on dialysis therapy irrespective of what is in the patient's best interests. In addition to the ownership issue, having a large number of dialysis patients increases the income of the nephrologist. Reimbursement for dialysis visits is greater than for office visits. Moreover, one can see many patients in a sitting, again increasing one's income. With minimal oversight of who is placed on dialysis therapy, such a system is ripe for abuse. Filling out the 2728 form appears to be more of a formality than producing a document that is reviewed and analyzed for appropriate criteria. It also is possible that classification of chronic kidney disease into 5 stages has contributed to this. If a patient is in stage 5, starting dialysis therapy can be justified with minimal need for documentation. A more robust system should be introduced such that patients who are started on dialysis therapy truly need such a life-changing therapy. Rather than starting dialysis therapy at an arbitrary glomerular filtration rate, the decision to place a patient on dialysis therapy should take into account a number of other factors, as recently outlined by Rosansky et al.
      • Rosansky S.
      • Glassock R.J.
      • Clark W.F.
      Early start of dialysis: a critical review.

      Acknowledgements

      Financial Disclosure: The author declares he has no relevant financial interests.

      References

        • Harris A.
        • Cooper B.A.
        • Li J.J.
        • et al.
        Cost-effectiveness of initiating dialysis early: a randomized controlled trial.
        Am J Kidney Dis. 2011; 57: 707-715
        • Manns B.J.
        • Quinn R.R.
        Early dialysis of no benefit to the patient or the health care system.
        Am J Kidney Dis. 2011; 57: 649-650
        • Rosansky S.
        • Glassock R.J.
        • Clark W.F.
        Early start of dialysis: a critical review.
        Clin J Am Soc Nephrol. 2011; 6: 1222-1228

      Linked Article

      • Cost-Effectiveness of Initiating Dialysis Early: A Randomized Controlled Trial
        American Journal of Kidney DiseasesVol. 57Issue 5
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          Planned early initiation of dialysis therapy based on estimated kidney function does not influence mortality and major comorbid conditions, but amelioration of symptoms may improve quality of life and decrease costs.
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      • Early Dialysis of No Benefit to the Patient or the Health Care System
        American Journal of Kidney DiseasesVol. 57Issue 5
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          As a general rule, physicians should only offer therapies to patients that are associated with improved survival, decreased morbidity, or improved quality of life. Given limited health care budgets, the cost of providing therapies is an important additional consideration for health care providers. In patients without kidney function, dialysis is life saving. However, dialysis also is intrusive and resource intensive, and significant controversy has existed for more than 20 years regarding the optimal time to initiate therapy.
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      • In Reply to ‘Regarding Early Initiation of Dialysis’
        American Journal of Kidney DiseasesVol. 58Issue 3
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          The study centers in the IDEAL (Initiating Dialysis Early and Late) Study were publicly funded and hence there is little obvious financial incentive driving early-start dialysis therapy. If anything, there may be an incentive to delay dialysis therapy (although this is not tested in the trial). We agree with Dr Senekjian1 that there is a case to mitigate any perverse financial incentives in a health care system that encourages early initiation of dialysis therapy based on a single measurement of kidney function, such as glomerular filtration rate (GFR).
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