Kidney Disease Outcomes Quality Initiative Guidelines Research Articles

Renal Dietitians Lack Time and Resources to Follow the NKF KDOQI Guidelines for Frequency and Method of Diet Assessment: Results of a Survey

This study was conducted to determine how often renal dietitians assess patients' diets and what methods they use to collect and analyze the data. Data were collected through an anonymous online survey. The survey was distributed to renal dietitians during the winter of2012. Currently practicing renal dietitian members of the International Society for Renal Nutrition and Metabolism, the National Kidney Foundation Council on Renal Nutrition, the Academy of Nutrition and Dietetics Renal Practice Group, and the RenalRD listserve were invited to participate. Of 599 usable responses received, 91% worked in the United States. The main outcome measure was dietitian compliance with Kidney Disease Outcomes Quality Initiative (KDOQI) nutrition assessment guidelines. Most dietitians collect dietary intake data when certain laboratory results are abnormal (70%) whereas 6.5% biannually collect dietary intake data (recommended by KDOQI). The most common reasons for not collecting dietary intake data more frequently were lack of time (42%) and software (25%). Most dietitians determine the frequency of dietary intake assessment on their own (60%) whereas 10% follow the KDOQI guidelines. The most common method of dietary intake data collection was a typical day recall (50%), although 8% reported using a 3-day food record as recommended by KDOQI. The most common method for analyzing dietary intake data was "estimate in my head" (62%) followed by calculate by hand (24.5%). Renal dietitians do not follow the KDOQI guidelines for diet assessment because of time constraints. Research must explore which nutrition assessment tools may improve patient outcomes and can also be completed within the time allotted for nutritioncare.

Appropriateness of anemia management in hemodialysis patients

The anemia of end stage renal disease (ESRD) is common and often severe complication that can be managed successfully by erythropoiesis-stimulating agents (ESA) administration. Aims To investigate current practice of anemia management in hemodialysis patients and to assess the appropriateness of anemia management by comparing observed practice to the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommendations. Settings and design The study was conducted at two hemodialysis centers in Riyadh, Saudi Arabia. Data on anemia parameters, comorbidities, ESA dosing and iron supplementation were collected. The data were collected for 7 months retrospectively from April to the end of May 2008 and prospectively from June to October 2008. Patients who were over 18 years of age with ESRD undergoing hemodialysis were included. Patients were excluded if they have cancer or receiving chemotherapy or radiotherapy. Results Data were collected from 87 patients. Mean Hgb value for those patients was 11.16 ± 0.97 g/dL. Thirty-nine patients (45%) had mean Hgb values between 11.0 and 12.0 g/dL the target range recommended by KDOQI guideline. The mean weekly prescribed dose of erythropoietin was 8099 ± 5946 IU/Week (135 ± 99 IU/kg/Week). Information on ferritin concentrations was available for 48 (55%) patients. The mean serum ferritin concentration for those patients was 693 ± 420.5 ng/mL. Fifty-two patients had transferrin saturation (TSAT) values recorded. The mean TSAT value was 38.5 ± 19.7%. Conclusions: There is an opportunity to improve anemia management in hemodialysis patients particularly thorough evaluation of causes of inadequate response rate and better monitoring and management of iron status.

Definition of chronic kidney disease and measurement of kidney function in original research papers: a review of the literature

Over the past decade, chronic kidney disease (CKD) has become an area of intensive clinical and epidemiological research. Despite the clarity provided by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, there appears to be within the CKD research literature significant disagreement on how to define CKD and measure kidney function. The objectives of this study were to investigate the variety of methods used to define CKD and to measure kidney function in original research papers as well as to investigate whether the quality of the journal had any effect on the quality of the methodology used. This was a descriptive review and not a meta-analysis. Information was extracted from each article including publication details (including the journal's impact factor), definition of CKD, method used to estimate kidney function and quantity of serum creatinine readings used to define CKD. An electronic search of MEDLINE through OVID was completed using the search term CKD. The search was limited to articles in English published in 2009. Studies were included in the review only if they were original research articles including patients with CKD. Articles were excluded if they reported data from a paediatric population, a population solely on dialysis or if there was no full-text access through OVID. Each article was assessed for quality with respect to using KDOQI CKD definition criteria. A description of the pooled data was completed and chi-square tests were used to investigate the relation between article quality and journal quality. Analysis was carried out using SPSS (15.0) and a P-value of <0.05 was considered to indicate statistical significance. The final review included 301 articles. There were a variety of methods used to define CKD in original research articles. Less than 20% (n = 59) of the articles adhered to the established international criteria for defining CKD. The majority of articles (52.1%) did not indicate the quantity of serum creatinine measurements used to define CKD. The impact factor or specialist nature of the scientific journal appears to have no bearing on whether or not published articles use the gold standard KDOQI guidelines for labelling a patient with a diagnosis of CKD. This review of literature found that a variety of definitions are being used in original research articles to define CKD and measure kidney function which calls into question the validity and reliability of such research findings and associated clinical guidelines. International consensus is urgently required to improve validity and generalizability of CKD research findings.

Two Years After a Quality Improvement Intervention for Chronic Kidney Disease Care in a Primary Care Office

Implementation of evidence-based Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines is of increasing clinical importance. This study evaluates the long-term impact of a chronic kidney disease (CKD) quality improvement (QI) project. A retrospective chart review was performed at a family practice that completed a QI project 2 years previously. In a study population of 195 patients, CKD recognition decreased during the maintenance period from 70% to 60.8% (P = 1.98), from a baseline of 38.1%, and anemia recognition declined from 70% to 50% (P =.132), from a baseline of 35%. Evaluation for parathyroid hormone, vitamin D, and phosphate decreased from 44% to 33% (P =.216), from a baseline of 4.8%. Referrals to nephrologists decreased from 77% to 61% (P = .369), from a baseline of 14%. The decrement in KDOQI guideline compliance during the maintenance period was not statistically significant, nor was there a return to baseline values. This suggests that the intervention provided the education and reinforcement necessary to effect long-term change.

Do Differences in Dialysis Prescription Impact on KDOQI Bone Mineral Targets? The Pan Thames Renal Audit

Background and Objectives:Patients achieving the Kidney Disease Outcomes Quality Initiative (KDOQI) bone mineral clinical practice guidelines have been reported to have improved survival. Many factors affecting calcium and phosphate control are not modifiable; however, we wished to determine whether differences in dialysis treatment could affect achievement of KDOQI clinical guideline targets. Methods: We audited pre-mid-week session calcium and phosphate levels in 5,324 adult patients receiving thrice weekly dialysis in the 14 Pan Thames centres: 60% male, mean age 62 ± 16 years, median dialysis vintage 29 months (14–58), 84% treated by haemodialysis, 16% by online haemodiafiltration, median session time 4.0 h (3.5–4.0). Results: Patients achieving the KDOQI guidelines varied between the centres: 23.4–60% for calcium, 31.7–56.7% for phosphate, 60–87.3% for calcium-phosphate product, 17.1–46.8% for parathyroid hormone (PTH) and 1.8–10.8% for all 4 targets. Those centres which used the highest dialysate calcium concentrations (1.5 mmol/l, 3 mEq/l) had more patients above the KDOQI serum calcium and more below the PTH target, than those centres using the lowest calcium dialysates (1 mmol/l, 2 mEq/l), with χ² = 85.1 and χ² = 52.4, p < 0.001, respectively. On logistic regression analysis, serum phosphate was negatively associated with duration of dialysis session time (F = 21.4, p = 0.000) and haemodiafiltration (F = 9.6, p = 0.000), respectively. Conclusions: Although many of the factors determining calcium and phosphate control in haemodialysis patients are unmodifiable, dialysate calcium concentration, the duration of the dialysis session and haemodiafiltration all had an impact on calcium, phosphate and PTH.

Deficient Counseling on Physical Activity among Nephrologists

Background: An evaluation of exercise counseling practices among nephrologists in 2001 demonstrated few clinicians assessing patients’ levels of physical activity (PA) and counseling to increase activity. Recent Kidney Disease Outcomes Quality Initiative (KDOQI) cardiovascular guidelines recommended that nephrologists counsel patients to increase PA. Our objective was to ascertain whether nephrologists’ counseling practices have changed. Methods: We administered a 30-item survey regarding exercise counseling to nephrologists attending the ASN meeting in 2007. Some questions were adapted from a prior survey administered in 2001 to assess differences in practice patterns compared to 6 years earlier. Results: Participants answered questions regarding opinions and practices relevant to PA (n = 198), KDOQI guidelines, self-reported PA, and demographic information (n = 173). Participants were 44 ± 11 years of age, 48% practicing in the USA, and 76% male. In multivariate analysis, older nephrologists (OR; 95% CI) (3.3; 1.2–9.0) and those more physically active (5.5; 2.0–14) were more likely to ask and counsel patients about PA. Opinions associated with less counseling behavior included lack of confidence in ability to discuss PA (0.2; 0.05–0.5). Multivariate comparison to previous respondents (n = 503) showed current nephrologists were not asking and counseling more (1.2; 0.81–1.8). Conclusion: Despite new guidelines, counseling behavior has not increased. Published guidelines are insufficient to reach younger nephrologists.

Meeting KDOQI Guideline Goals at Hemodialysis Initiation and Survival during the First Year

To determine, in a national cohort of incident hemodialysis patients, whether meeting a greater number of National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guideline goals at dialysis initiation was independently associated, in a graded manner, with lower first-year mortality rates. Patients who initiated hemodialysis between June 1, 2005, and May 31, 2007, in the US were included in this retrospective cohort analysis. Guidelines examined were (1) use of arteriovenous fistula or graft at initiation; (2) hemoglobin > or = 11 g/dl; and (3) albumin at goal. The primary predictor variable was number of guideline goals (zero, one, two, or three) met at dialysis initiation. Cox regression analysis was used to compare time to death, adjusting for baseline characteristics. At dialysis initiation, 59%, 31%, 9%, and 1.6% of patients met zero, one, two, or three guideline goals, respectively (total n = 192,307). After multivariate adjustment, mortality hazard ratios (95% confidence intervals) were 0.81 (0.80 to 0.83) for patients who met one, 0.53 (0.51 to 0.56) for patients who met two, and 0.34 (0.30 to 0.39) for patients who met three guideline goals, compared with patients who met none. Meeting each individual goal was also associated with lower mortality. These findings suggest a graded association between meeting a greater number of evidence-based guideline goals at dialysis initiation and lower risk of death during the first year on dialysis.

KDOQI US Commentary on the 2009 KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of CKD–Mineral and Bone Disorder (CKD-MBD)

This commentary provides a US perspective on the 2009 KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). KDIGO is an independent international organization with the primary mission of the promotion, coordination, collaboration, and integration of initiatives to develop and implement clinical practice guidelines for the care of patients with kidney disease. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI), recognizing that international guidelines need to be adapted for each country, convened a group of experts to comment on the application and implementation of the KDIGO guideline for patients with CKD in the United States. This commentary puts the KDIGO guideline into the context of the supporting evidence and the setting of care delivered in the United States and summarizes important differences between prior KDOQI guidelines and the newer KDIGO guideline. It also considers the potential impact of a new bundled payment system for dialysis clinics. The KDIGO guideline addresses the evaluation and treatment of abnormalities of CKD-MBD in adults and children with CKD stages 3-5 on long-term dialysis therapy or with a kidney transplant. Tests considered are those that relate to laboratory, bone, and cardiovascular abnormality detection and monitoring. Treatments considered are interventions to treat hyperphosphatemia, hyperparathyroidism, and bone disease in patients with CKD stages 3-5D and 1-5T. Limitations of the evidence are discussed. The lack of definitive clinical outcome trials explains why most recommendations are not of level 1 but of level 2 strength, which means weak or discretionary recommendations. Suggestions for future research highlight priority areas.

Interventional Nephrology: Core Curriculum 2009

Interventional Nephrology: Core Curriculum 2009

The D&amp;T Report

The D&amp;T Report

Daily oral 25-hydroxycholecalciferol supplementation for vitamin D deficiency in haemodialysis patients: effects on mineral metabolism and bone markers

Vitamin D deficiency is frequently observed in end-stage renal disease (ESRD) patients; however, the effects of vitamin D supplementation have rarely been reported. We aimed to assess the effects of daily 25(OH)D(3) supplementation on mineral metabolism, bone markers and Kidney Disease Outcomes Quality Initiative (KDOQI) targets in haemodialysis (HD) patients for a period of 6 months. HD patients were included in this study if their serum 25(OH)D level was <75 mmol/L. Oral 25(OH)D(3) was administered daily at 10-30 microg/day based on the severity of the deficiency. Characteristics of the patients were compared from the baseline to 6 months on the basis of their response to 25(OH)D(3) administration and the patients were divided into three groups. Patients who showed partial response [serum 25(OH)D <75 nmol/L] were placed in group 1, those who showed normal response [serum 25(OH)D ranging from 75 to 150 nmol/L] were placed in group 2 and those who showed excessive response [serum 25(OH)D >150 nmol/L] were placed in group 3. Of the 253 HD patients, 225 (89%) showed vitamin D insufficiency or deficiency, 172 were included in the study and 149 patients completed the study. After 6 months of treatment [mean daily 25(OH)D(3): 16 +/- 5 microg/day], the serum 25(OH)D level increased (30 +/- 19 to 126 +/- 46 nmol/ L, P < 0.001), with 13% of patients in group 1, 57% in group 2 and 30% in group 3. The serum intact parathyroid hormone (iPTH) level decreased (235 +/- 186 to 189 +/- 137 pg/mL, P = 0.05), except in group 1. Bone alkaline phosphatase (BALP) showed a tendency to normalize (23 +/- 16 to 18.3 +/- 11 microg/L, P < 0.05), leading to a decrease in alfacalcidol administration from 66% to 43% (P < 0.05), except in group 1. The KDOQI targets achieved increased significantly for serum calcium (76% to 85%) and phosphate levels (66% to 77%) in all patients. The serum albumin level increased in all groups (34.6 +/- 4 to 36.8 +/- 4 g/L, P < 0.05), without any significant improvement in normalized protein catabolic rate (nPCR) or C-reactive proteins (CRP). With a daily dose ranging from 10 to 30 microg, daily oral 25(OH)D(3) supplementation corrects most vitamin D deficiencies or insufficiencies in HD patients, without any evident toxicity. The main effects observed included correction of excessive bone turnover, despite less alfacalcidol administration, increase in serum albumin level and increase in the percentage of patients with serum calcium and phosphorus levels within the recommendation of the KDOQI guidelines.

Hemodialysis access success: beyond the operating room

Background Publication of the Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines has reinforced an already increased focus within the Veterans Health Administration (VHA) on arteriovenous (AV) hemodialysis (HD) vascular access. Meeting these KDOQI goals has been the responsibility of individual VHA centers. We responded by organizing a dedicated HD AV clinic to provide preoperative evaluation and postoperative follow-up. Methods The records of 130 patients referred from January 2004 through June 2006 to our AV HD clinic were retrospectively reviewed. A minimum of 6 months of postoperative follow-up was required. Results AV fistulae were performed in 71% of the patients, with approximately 45% being Brescia-Cimino fistulae. Importantly, only 38% of AV fistulae matured and were used without secondary intervention. The remaining 62% of AV fistulae each required 2.2 ± .3 interventions. The final AV fistula use rate was approximately 85%. Conclusions To meet these KDOQI guidelines, the VHA should continue to support the concept of dedicated AV HD teams and clinics. This is essential because the majority of our new AV fistulae required secondary intervention for AV fistulae maturation and use. A dedicated HD access team should better be able to assess AV fistula maturation and organize subsequent intervention to promote AV fistulae use.

Which Targets in Clinical Practice Guidelines Are Associated with Improved Survival in a Large Dialysis Organization?

Professional organizations have developed practice guidelines in the hope of improving clinical outcomes. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has set targets for dialysis dosage (single-pool Kt/V), hematocrit, serum albumin, calcium, phosphorus, parathyroid hormone, and BP for hemodialysis (HD) patients. Several guidelines are largely based on results from observational studies. In contrast to other parameters, BP values within the KDOQI guidelines have been associated with increased mortality. Therefore, it was postulated that having multiple parameters that satisfy the current guidelines, except those for BP, is associated with improved survival among HD patients. A retrospective analysis was conducted of incident HD patients who were treated at facilities operated by Dialysis Clinic Inc., a not-for-profit dialysis provider, between January 1, 1998, and December 31, 2004 (n = 13,792). Cox proportional hazards models were used to assess the association between satisfying guidelines and mortality. Values within guidelines for single-pool Kt/V, hematocrit, serum albumin, calcium, phosphorus, and parathyroid hormone were associated with decreased mortality (P < or = 0.0001). The largest survival benefit was found for serum albumin (hazard ratio [HR] 0.27; 95% confidence interval [CI] 0.24 to 0.31). Satisfying these six guidelines simultaneously was associated with an 89% reduction in mortality (HR 0.11; 95% CI 0.06 to 0.19]). Conversely, BP values satisfying the guideline were associated with increased mortality (HR 1.90; 95% CI 1.73 to 2.10). Because this target was largely extrapolated from the general population, a randomized, controlled trial is needed to identify the optimal BP for HD patients.

How to define anemia in children with chronic kidney disease?

In a cross-sectional study, we compared the prevalence of anemia based on age- and gender-specific reference intervals for hemoglobin (Hgb) and hematocrit (Hct) with the Kidney Disease Outcomes Quality Initiative (KDOQI) anemia definition (Hgb < 110 g/L) in 351 children with chronic kidney disease (CKD) stages I-V. Cystatin C-based GFRs were 122 +/- 36 mL/min/1.73 m(2) in patients with stage I CKD (n=196), 76 +/- 8 mL/min/1.73 m(2) for stage II (n=104), 45 +/- 9 mL/min/1.73 m(2) for stage III (n=36), and 22 +/- 5 mL/min/1.73 m(2) in patients with stage IV+V CKD (n=15). Fifty-nine patients received iron therapy and 32 patients were treated with Darbepoetin. For Hgb, a total of 90 patients fit the age and gender derived criteria, compared to only 54 patients identified by the KDOQI guidelines (p=0.0010). Similarly, for Hct, a total of 78 patients fit the age and gender derived criteria, which was a significantly higher proportion than the 56 identified by the KDOQI guidelines (r=0.22, p=0.0435). There was a significant correlation between the GFR and both the Hgb Z-score (p=0.0068) and the Hct Z-score (p=0.0128). There was poor agreement between conventional and KDOQI definitions of anemia in children with CKD.

Anemia of Kidney Disease and Clinical Practice Guidelines

In the 15 yr since the Institute of Medicine defined clinical practice guidelines (CPG) as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances” (1), there has been an upsurge in their promulgation. The Agency for Healthcare Research and Quality lists more than 2000 active CPG. The factors that have driven the profusion of clinical practice guidelines are essentially the same that have driven a general increase in evidence-based decision-making and the field of outcomes research. Evidence strongly suggests that standardization of medical practice can provide cost-effective care that improves outcomes (2). Despite the seemingly compelling virtue of CPG, they are certainly not a panacea for all of the ills in health care delivery. CPG usually focus on improving the management of one particular disease, often neglecting to provide guidance on the integration of complex medical regimens for patients with multiple comorbid diseases (3,4). When CPG are linked to clinical performance measures, the result can be an increase in auditing and regulation without necessarily improving patient outcomes (5,6). Grading evidence for CPG remains complex, with multiple varying systems and approaches available (7,8). Different conclusions can arise when applying different grading systems to the same body of evidence …

Impact of the Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Bone Metabolism and Disease in a Large Dialysis Network

The impact of the Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease has not been assessed. We compared albumin-adjusted serum calcium, phosphate, calcium x phosphate (Ca x P) product, and parathyroid hormone (PTH) values among active hemodialysis patients who received care at Dialysis Clinic Inc facilities during 8-month periods before (n = 9,516) and after (n = 9,543) the October 2003 release of the KDOQI guidelines. We examined the impact of missed sessions, abbreviated sessions, and patient-dietitian ratio on achievement of consistent control (defined as >or= 75% values within guideline targets) for each parameter. We also evaluated whether achievement of consistent control of a given parameter precluded control of another. There was a modest decrease in mean per-patient concentration for all mineral metabolic indicators after release of the guidelines. Similarly, the proportion of values within the recommended ranges for serum calcium, phosphate, and Ca x P product increased, but remained unchanged for PTH. The likelihood of achieving consistent control for each indicator increased when other parameters were concomitantly in range. Missed dialysis sessions were associated with a lower likelihood of achieving consistent control of calcium, phosphate, and Ca x P product levels, whereas abbreviated sessions were associated inversely with consistent achievement of phosphate and Ca x P product target levels. Variations in patient-dietitian ratio had no discernible association with mineral metabolic control. The KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease had a small, but noticeable, effect in the year after their release. Additional studies should evaluate whether achievement of the prescribed target levels confers an advantage with respect to relevant clinical outcomes.

Economic implications of non-adherence to treatment recommendations for hemodialysis patients with anemia

Background Treatment of patients receiving hemodialysis who have anemia varies considerably despite the availability of established practice guidelines from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI). Objective To compare actual use of erythropoietin (EPO) and intravenous (IV) iron with that recommended in KDOQI guidelines. Methods A budget impact model was used to calculate costs per member per month (PMPM) for actual practice versus recommended practice were calculated using Medicare reimbursement rates for EPO and IV iron. A sensitivity analysis tested the impact of varying the recommended dosages by ± 50%. Results For EPO, a net savings PMPM of $257 (if administered by IV ) or $252 (if administered subcutaneously) could be achieved with adherence to KDOQI guidelines. Adherence to KDOQI recommendations for IV iron would increase Medicare reimbursements for this drug by an estimated $6 PMPM. Sensitivity analysis revealed a significant potential savings even if the dose of EPO used in practice was increased by 50%. Conclusions In the face of limited resources and changing reimbursement policies, dialysis providers will need to find ways of reducing costs without compromising the quality of care. Clinical practice guidelines such as KDOQI can be used to assist providers in meeting this challenge. Among Medicare patients who have anemia of chronic kidney disease, adherence to KDOQI treatment recommendations could translate into a significant savings for Medicare. Our findings provide incentive for payers and dialysis centers to examine their current practices and improve the quality and efficiency of anemia treatment in this population.

More than a Decade of Experience and Still No Consensus

During the past decade, the integration of recombinant human erythropoietin (EPO) and maintenance intravenous iron therapy into standard anemia management protocols has significantly altered the treatment of anemia in patients who are on hemodialysis (HD). Hemoglobin levels have increased inexorably and now average almost 12 g/dl (1). The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines state that intravenous iron usually is required for the provision of optimal iron stores to maximize erythropoiesis-stimulating agent (ESA) efficiency in patients who are on dialysis (2). Intravenous iron therapy is needed in patients who are on HD because these patients experience ongoing blood (iron) losses, and oral iron fails to maintain adequate iron stores. Efficient erythropoiesis requires both iron and erythropoietin (2). In these patients, intravenous iron improves iron and hematologic parameters, with health benefits of intravenous iron outweighing potential adverse effects. Use of maintenance iron improves patients’ response to EPO therapy (3), replaces patients’ ongoing iron losses, and helps to maintain patients’ target hemoglobin and hematocrit ranges. These benefits of intravenous iron therapy have been achieved at storage iron levels far below those that generally were seen with transfusions in the pre-EPO era (4). However, according to Medicare claims data from the US Renal Data System, only slightly more than half of HD patients receive intravenous iron therapy at least once a month, demonstrating that although intravenous iron therapy is being administered to the majority of HD patients, it may not be used on a regular basis (5). Although the reasons for lack of “regular” intravenous iron may be many, such as concerns about iron parameters, particularly ferritin levels, it also may reflect variation in protocols among centers. The KDOQI guidelines were a milestone in the development of effective, standardized principles for the management of anemia in patients with chronic …

Factors Influencing Route of Administration for Epoetin Treatment Among Hemodialysis Patients in the United States

Published clinical guidelines advocate subcutaneous (SC) administration for epoetin therapy, although this is practiced among only 7% of all hemodialysis patients. Despite this disparity, few studies have examined factors associated with route of epoetin administration in hemodialysis patients. Data from the Centers for Medicare & Medicaid Services End-Stage Renal Disease Clinical Performance Measures Project were used to identify 13,854 patients receiving hemodialysis in 3,069 dialysis facilities from October to December in 1999 and 2000. Unadjusted associations were examined by using t-test and chi-square test. Adjusted associations were estimated by using generalized estimating equations to control for clustering of patients within the same dialysis facility. In the United States, use of the SC route of epoetin administration varies widely across the country. After adjusting for patient sociodemographics and comorbidities, the greatest rates of SC therapy are found in the Midwest and West, in providers not affiliated with chains, and in hospital-based and not-for-profit freestanding units. Previous exposure to SC administration (as a predialysis or peritoneal dialysis patient) predicted subsequent SC use, for-profit and large chains were significantly less likely to use SC administration, and increased use of injectable drugs overall (to maximize income) was associated with less SC use. In addition to regional variation in SC use, study findings indicate that physician decision making for epoetin administration route is influenced primarily by type of ownership and financial incentives. Adherence to published clinical guidelines was not a consistent predictor of SC use. Given the similar effectiveness, but significantly decreased dose associated with SC epoetin, these findings suggest an enormous opportunity for cost savings for the Medicare program.