National Kidney Foundation-Dialysis Outcomes Quality Initiative Research Articles

Small incision basilic vein transposition technique: A good alternative to standard method

End-stage renal disease is a significant health problem. The primary use of the autogenous arteriovenous access is recommended by NKF-DOQI (National Kidney Foundation-Dialysis Outcomes Quality Initiative) guidelines. Though basilic vein transposition is well established in multiple failed fistulae's and obese patients, it requires large incision and morbidities like edema and infection. To avoid such compilations we, at our institution, adopted a small incision technique using two small 3-4 cm incisions. This method is inspired by videoendoscopic minimally invasive method used to dissect the basilic vein, thus avoiding extensive dissection and related morbidities.

A Vascular Access Team Can Increase AV Fistula Creation in Pediatric ESRD Patients: A Single Center Experience

The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) recommends the use of a permanent vascular access for pediatric hemodialysis (HD) patients; however, central venous catheters are the most common vascular access used among children. In children receiving HD, central venous catheters, while suboptimal, are the most common vascular access used. As such, it is imperative that pediatric HD providers optimize vascular access techniques. We report outcomes of arteriovenous fistula (AVF) creation by a single surgeon in pediatric HD patients dialyzed at a single center. We further describe our experience and outcomes with the use of the operating microscope in the United States in children receiving HD under 15 kg in weight and as young as 4 years of age. AVF usage rates as well as short- and long-term patency rates can be quite high with proper management. We further illustrate that the Fistula First principles can be applied to the pediatric population in the setting of a single surgeon with single center experience. As such, we have surpassed the current NKF-DOQI recommendation of 50% fistula use in prevalent HD patients.

Excellent performance of one-stage brachial–basilic arteriovenous fistula

According to the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) and the European Guidelines, the first and second choice for vascular access for haemodialysis are the radial-cephalic and brachial-cephalic arteriovenous fistula (AVF). Autogenous fistulas have a longer functional lifetime, less thrombotic complications and a lower infection risk compared with prosthetic implants. If it is impossible to create a brachial-cephalic AVF or after failure, either a brachial-basilic (BB) or a prosthetic forearm loop AVF may be considered. To determine the outcome of BB-AVFs, we retrospectively surveyed the results of this type of vascular access. All BB-AVF patient records over a 6 year period were subtracted from an academic hospital registry. Primary failure and primary, assisted primary and secondary patency rates were calculated with the Kaplan-Meier method. Sex, diabetes mellitus (DM), pre-operative duplex diameters, complications and interventions were recorded and correlated with the patency rates. A total of 31 BB-AVFs were created in a one-stage surgical procedure. Of the patients, 36% were male and 19% had DM. Only one patient had a primary failure, leaving 30 (97%) of the BB-AVFs functional for dialysis treatment. Four patients died within 1 year after the operation, one of them from a catheter sepsis. Primary, assisted primary and secondary patency rates after 1 year were, 58, 83 and 90%, respectively. Patient characteristics and pre-operative duplex parameters did not influence patency rates. The BB-AVF is an excellent third choice option for vascular access.

Transposition of the brachial vein: a new source for autologous arteriovenous fistulas

Increasing the prevalence of arteriovenous fistula over arteriovenous synthetic graft is critical for decreasing the morbidity and costs of dialysis patients. This is highlighted in the guidelines set forth by The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI), which encourage the increased use of autogenous vein in fistula creation. In addition to the basilic and cephalic veins, another source of autogenous vein is the brachial vein, a deep vein of the upper arm. Here we describe 2 patients with absence of adequate superficial veins, in whom a transposed brachial vein was used for the creation of an arteriovenous fistula.

Developing clinical performance measures based on the Dialysis Outcomes Quality Initiative Clinical Practice Guidelines: process, outcomes, and implications1,2

Background:The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Practice Guidelines established a widely accepted set of recommendations for high-quality dialysis care. To enhance the End-Stage Renal Disease Core Indicators Project, an ongoing effort to assess and improve dialysis care in the United States, the Centers for Medicare and Medicaid Services (CMS) commissioned a project to develop clinical performance measures (CPMs) based on the NKF-DOQI guidelines. Methods:The CMS contracted with Qualis Health, a private nonprofit organization serving as a Medicare Quality Improvement Organization, to facilitate a 9-month project to develop dialysis CPMs with the participation of a broad range of stakeholders from the renal community. Work groups were established to develop CPMs addressing 4 areas: hemodialysis adequacy, peritoneal dialysis adequacy, vascular access management, and anemia management. The NKF-DOQI guidelines were prioritized based on the strength of the evidence supporting the guidelines, the feasibility of developing performance measures, and the significance of the areas addressed to the quality of care delivered to dialysis patients. Expert panels developed data specifications, sampling approaches, data-collection tools, and analytic strategies. Results:Sixteen CPMs were developed based on 22 of 114 NKF-DOQI guidelines. After establishing reliability through field-testing of data-collection instruments, the CPMs were applied to a sample of 8,838 randomly selected hemodialysis patients and 1,650 randomly selected adult peritoneal dialysis patients in summer 1999. Conclusion:The development of CPMs based on the NKF-DOQI Clinical Practice Guidelines for dialysis care was accomplished in a timely and effective manner by engaging a broad range of stakeholders and technical experts. The CPMs are important tools to assess and improve the quality of dialysis care in the United States. Few comparable efforts exist in other fields of medicine.

Epidemiology of hemodialysis vascular access infections from longitudinal infection surveillance data: predicting the impact of NKF-DOQI clinical practice guidelines for vascular access.

National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Vascular Access Guidelines 29 (40% of prevalent patients should have a native fistula) and 30 (<10% use of catheters for chronic hemodialysis) are currently based on opinion, rather than published evidence. The impact of these guidelines on reducing vascular access infection rates is unknown and was tested using data from an outpatient prospective cohort analysis. Patients undergoing hemodialysis from January 1998 through December 2000 at six outpatient facilities in Idaho and Oregon were evaluated prospectively for vascular access infections. There were 111,383 dialysis sessions (DSs) with 471 infections identified (4.2 infections/1,000 DSs). The risk for infection relative to arteriovenous (AV) fistulae was highly dependent on type of access used: 2.2 (P = 0.002) for AV grafts, 13.6 (P < 0.0001) for tunneled catheters, and 32.6 (P < 0.0001) for temporary catheters. Based on incidence infection rates, the number of infections predicted to occur with implementation of guidelines 29 and 30 in this population was calculated, and the percentage of reduction in infection was determined. Following either guideline 29 or 30 alone would have predictably prevented 103 or 97 total infections (22% and 21% reduction) and 40 or 51 bloodstream infections (24% and 30% reduction), respectively. Following both guidelines simultaneously would have prevented 151 total infections (32% reduction) and 64 bloodstream infections (38% reduction). These epidemiological data firmly establish that a major risk for vascular access infections is the type of access used (temporary catheters > tunneled catheters > AV grafts > AV fistulae). Furthermore, they strongly support the role of these NKF-DOQI guidelines in preventing infectious complications attributed to vascular access.

Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas

Renewed interest in transposed brachiobasilic fistulas has occurred since the release of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines because it is an alternative method to achieve an upper arm fistula in patients who cannot achieve a functional brachiocephalic fistula. The objective of this study was to compare outcomes among transposed brachiobasilic fistulas, upper arm grafts, and brachiocephalic fistulas. A cohort of patients with upper arm accesses was retrospectively identified. Access outcomes were determined from medical records and contact with physicians, dialysis providers, and patients. Primary outcome was thrombosis-free survival. Secondary outcomes were primary failure, time to use, risk of catheter-related bacteremia, need for intervention, incidence of access-related complications, cumulative, and functional patency. Group differences in age, sex, race, diabetes, peripheral vascular disease, and number of previous accesses were adjusted for in the analysis where appropriate. Transposed brachiobasilic fistulas, upper arm grafts, and brachiocephalic fistulas were compared in 59, 82, and 56 patients, respectively. Compared with transposed brachiobasilic fistulas, upper arm grafts were more likely to thrombose with an adjusted relative risk (RR) of 2.6 (95% CI, 1.3 to 5.3) excluding primary failures and 1.6 (95% CI, 1.0 to 2.7) when accounting for the lower risk of primary failure for grafts. Transposed brachiobasilic fistulas also required less intervention (0.7 vs. 2.4 per access-year, P < 0.01) and were less likely to become infected (0 vs. 13%, P < 0.05) than grafts. Mature brachiocephalic fistulas were less likely to fail (RR 0.3, 95% CI, 0.1 to 1.0) and showed a trend for less thrombosis (RR 0.3, 0.1 to 1.1) than mature brachiobasilic fistulas. There was no significant difference in cumulative patency (failure-free survival) among the three types of access if primary failure was included at the median follow-up of 594 days. Transposed brachiobasilic fistulas provided catheter-free access one month sooner than brachiocephalic fistulas and one month later than upper arm grafts. Transposed brachiobasilic fistulas provide cumulative patency equivalent to upper arm grafts and brachiocephalic fistulas. They are less likely to thrombose and become infected than upper arm grafts. Compared with brachiocephalic fistula, they are more likely to mature but are at increased risk of thrombosis after maturation. Transposed brachiobasilic fistulas should be considered before placing an upper arm graft for patients that cannot achieve a functional brachiocephalic fistula.

What are the clinical correlates of adequate peritoneal dialysis?

The efficacy of peritoneal dialysis in terms of the clearance of small molecules such as urea and creatinine is referred to as "adequacy." Treatment guidelines and adequacy targets have been developed and distributed by the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) in an effort to reduce variations in end-stage renal disease (ESRD) treatment. Much effort has been made to determine the correlation between dialysis dose and various clinical outcome measures (eg, hospitalization, mortality) in adults in an attempt to define the optimal dialysis dose. The delineation of this issue in the pediatric ESRD population is more complex because of the small number of patients and the need to define sensitive outcome measures that are unique to children. The review addresses the possible clinical correlates of dialysis adequacy in children that exist today and the additional data on the topic that needs to be collected in the future.

Increasing AV fistulas: revisiting a time-tested solution.

Despite having the lowest complication rate of all hemodialysis accesses, the prevalence of autologous arteriovenous (AV) fistulas has declined to 28% in the United States. The reasons for this decline include high early AV fistula failure rates, long maturation times, the frequent need for emergent dialysis, unavailable or poor pre-ESRD programs and planning, patient resistance to the realities of impending ESRD, and financial disincentives to AV fistula placement. Despite these barriers, programs throughout the country have demonstrated the ability to increase AV fistula prevalence to more than 50%. The strategies employed have included increased reliance on upper arm brachiocephalic and transposed basilic vein fistulas, the use of preoperative imaging to identify the best sites for fistula creation, and aggressive attempts at salvage of nonmaturing fistulas. Other groups have systematically and successfully replaced failed grafts with upper arm brachiocephalic or bracheobasilic fistulas. These experiences clearly show that exceeding the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) goal of more than 50% fistula placement is achievable in the United States. Declining numbers of AV fistulas are the result of a combination of factors, including changes in our patient population and learned practice patterns coupled with a failure of our delivery system to provide education, timely referral, and incentives for fistula placement. Increasing AV fistula prevalence in the United States is achievable and will improve patient outcomes and decrease the costs of ESRD.

Coordination of Care in Disease Management: Opportunities and Financial Issues

Patients with end-stage renal disease (ESRD) and pre-ESRD require higher utilization of health care resources. Current reimbursement modalities contribute to the fragmentation of care, and inadequate financial information obscures the fiscal impact disease management's coordination of care can have for this population. Ignoring the extreme costs of the first 3 months of hemodialysis underestimates costs by as much as 16%. Potential areas of coordination and the financial benefits are discussed. In each venue of the care settings of a patient with chronic renal failure (CRF) they may receive excellent service. Too often there is not optimal coordination of care between these venues, and in fact the fragmentation of care can cause unnecessary wear and tear on the patient, and increases the overall expense to a health care system. Understanding sources of fragmentation, reimbursement effects, and potential corrections will enhance the patient's voyage through the system. This article provides some examples of the discoordination that presently exists and financial implications especially during the transition onto dialysis. In patients with end-stage renal disease (ESRD), each arena of care has criteria established to quantitate quality. None of the settings, whether it is the dialysis unit, the hospital, the skilled nursing facility, or the physician's office, exists in the absence of regulations. These may be state or federal, National Council on Quality Assurance (NCQA), Health Plan Employer Data and Information Set (HEDIS), water standards, Occupational Safety and Health Administration (OSHA), fire codes, physician peer review, Medicare billing, Health Care Finance Administration (HCFA), the ESRD networks, credentialing, health maintenance organization (HMO) insurance requirements, pharmacy benefits and formularies, safe harbors, "antikickback," or National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines. For all the providers of care, the other critical component is the ability to have adequate income to stay in business, and make a profit. Each becomes very astute at working within the confines of the regulatory restrictions to provide good care. However, the continuity of care cannot be the overwhelming issue for many of the providers. The only person that is involved in every arena is the patient. The only provider that currently crosses over most arenas is the nephrologist. But the other element that exists in each arena is a payer.

Improvement in hemodialysis vascular access outcomes in a dedicated access center.

There are more than 300,000 end-stage renal disease (ESRD) patients in the United States, with those on hemodialysis requiring vascular access for dialysis treatment. According to the 1999 annual report of the U.S. Renal Data System (USRDS), the leading cause of morbidity in this patient population is related to vascular access placement and the resultant complications. Vascular access procedures account for more than 10% of the annual ESRD budget and are conservatively estimated at $1 billion annually. The impact of dysfunctional vascular access on physician time, health care resources, and patient quality of life is profound. In 1997 I opened a freestanding, dedicated access center for the diagnosis and treatment of access-related disorders. This article summarizes the experience of this center. In our free-standing dialysis access center, a large referral base has been established consisting of 30 dialysis centers with approximately 2000 patients. During the 27 months from October 1997 to December 1999, 1087 patients were treated. These patients received 2862 access procedures (2.6 procedures/patient). Annualized, this gives a dysfunction rate of 1.15 episodes/patient/year at risk. Endovascular declotting procedures were performed 1282 times (45%) with a success rate (defined as one uneventful hemodialysis following the procedure) of 93% (1187/1282). Prospective angiography followed by percutaneous transluminal angioplasty was performed 703 times (24%). This procedure was successful 695 times for a success rate of 99%. There were 644 (23%) catheter procedures performed consisting of catheter placements, catheter exchanges through new or old tracts, and catheter removals. The success rate for catheter procedures was 99.1%. Complication rates were extremely low, both for major and minor complications, exceeding all published standards. Hemodialysis vascular access can be optimized in a freestanding, focused, outcomes-driven outpatient access center. Outcomes can meet or exceed the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines for vascular access while at the same time providing the patient with an outpatient procedure and the referring dialysis unit and nephrologist with an efficient, effective mode of patient care.

Methods used to evaluate the quality of evidence underlying the National Kidney Foundation-dialysis outcomes quality initiative clinical practice guidelines: Description, findings, and implications

This report describes the approach the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) used to assess the strength of published evidence pertinent to individual NKF-DOQI Clinical Practice Guidelines, as well as the relationship between that approach and methods used by the US Preventive Services Task Force, the Cochrane Collaboration, and the Agency for Health Care Policy and Research to rate the quality and/or strength of evidence. We also present the results of an analysis of the strength of evidence underlying the NKF-DOQI Guidelines showing that one cannot infer the quality of evidence reported in a study (rated either on a 0-to-1 scale or categorically as excellent, very good, good, fair, or poor) simply by knowing the type of study design used (randomized trial, nonrandomized trial, natural experiment, cohort study, cross-sectional study, case-control study, case report). Issues related to assessment of the strength of evidence underlying a practice guideline opposed to that reported in an individual study are highlighted.

Morbidity and mortality in redefining adequacy of peritoneal dialysis: a step beyond the National Kidney Foundation Dialysis Outcomes Quality Initiative.

The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) Peritoneal Dialysis (PD) Adequacy Work Group intentionally limited the scope of its work to address adequacy in terms of small-solute removal. This decision was based on the need for rigorous evidence and that mortality is the most objective parameter in the literature. This review attempts to more broadly redefine the concept of the adequacy of PD, particularly as it relates to the most common general medical problems that PD patients experience; namely, cardiovascular disease and malnutrition. Whereas we are sensitive to the developmental process of the NKF-DOQI, we are critical that the definition of adequacy may be too narrow, leading clinicians to overlook other important morbidities. We have reiterated the evidence that suggests a weekly solute clearance (Kt/Vurea) of 1.7 or greater is associated with better patient survival. The arguments to target a greater Kt/Vurea of 2.0 are challenged, yet the concept is ultimately supported. Because cardiovascular disease is the cause of death in half of all patients with end-stage renal disease, dialysis adequacy must be defined, in part, by the potential of that therapy to diminish cardiovascular maladies. Blood pressure, volume, left ventricular hypertrophy, and dyslipidemias are discussed in this context. Lastly, assumptions that increasing total solute clearance leads to improved nutrition in PD patients are challenged. We have attempted to expand on what the NKF-DOQI did not include, and we urge the dialysis community to seek the answers to the many controversies that remain. We need to redefine the adequacy of PD in a holistic manner and find outcome parameters that are not as final as death.

An innovative approach to temporary hemodialysis vascular access.

The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) has set down explicit and extensive guidelines for temporary and permanent hemodialysis vascular access. It is now incumbent on the nephrologist to ensure compliance to these standards. Two of our interventional nephrologists performed 402 central venous access procedures over a 12-month period (November 1996 to October 1997) to test the hypothesis that increased control over insertion technique would improve outcome. All but eight of the procedures were successfully completed, resulting in a failure rate of 2%. The expected serious procedural complication rate outlined in the NKF-DOQI standards is 2%. Our complication rate was 0.7% if all procedures were accounted for and 0.89% for just internal jugular and subclavian catheters. We conclude that the use of interventionally trained nephrologists and strict control of technique can improve outcome in temporary vascular access procedures.

European best practice guidelines for the management of anaemia in patients with chronic renal failure.

Best practice guidelines recommend management strategies and attempt to set standards for optimal patient care. The momentum towards formulating guidelines comes not only from health care professionals, but also from health care management organizations, who need some way of measuring the quality of the services they purchase. The European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure have been drawn up by a Working Party including representatives of the European Renal Association/European Dialysis and Transplantation Association (ERA-EDTA) and the national nephrology societies of a cross-section of European countries. The guidelines draw on the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Best Practice Guidelines for the Treatment of Anemia in Chronic Renal Failure, but reflect European clinical practice and experience. They include additional publications, and new analysis and interpretation of the evidence base. Topics covered in the European guidelines include diagnosis of the anaemia of chronic renal failure, indications for starting treatment with epoetin, recommended minimum target haemoglobin concentrations, epoetin dosage and route of administration, assessing and optimizing iron stores, causes and management of epoetin resistance, and possible adverse effects of epoetin treatment. The guidelines are not intended to be prescriptive but rather to provide clinical guidance based on the best available evidence. The evidence supporting each guideline is graded, so that physicians may judge its reliability.

The Role of Patients in the Implementation of the National Kidney Foundation-Dialysis Outcomes Quality Initiative

Patients have a fundamental right to be involved in making decisions that affect their health care treatment and outcomes. Patients need to be knowledgeable about disease process and treatment options to exercise this right. The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Practice Guidelines on Hemodialysis Adequacy, Peritoneal Dialysis Adequacy, Treatment of Anemia of Chronic Renal Failure, and Vascular Access, introduced in 1997, include new clinical recommendations that may impact patient treatment choices. Access to these guidelines presents a unique professional opportunity to empower patients through education related to NKF-DOQI. This article highlights the role of patients in implementing NKF-DOQI in light of studies conducted by two renal patient organizations, the National Kidney Foundation (NKF) and the American Association of Kidney Patients (AAKP). Results from the AAKP survey indicate that end-stage renal disease patients are willing to change behavior to feel better and live longer. Results from the NKF focus study show that dialysis patients need to receive information about NKF-DOQI and understand its direct impact on patient outcomes. In addition, results from both studies reveal that patients feel strongly about participating in health care decisions that impact on their treatment and outcomes.

The Impact of the Dialysis Outcomes Quality Initiative Guidelines on the Care of the Pediatric End-Stage Renal Disease Patient

The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Guidelines for hemodialysis and peritoneal dialysis adequacy, management of vascular access, and management of anemia are based primarily on evidence derived from the experience of adult dialysis patients. However, these Guidelines can also be used to improve the care of children with end-stage renal disease (ESRD). Some of the guidelines are directly applicable to pediatric dialysis patients, such as the preferential use of the internal jugular vein for placement of a central venous catheter for dialysis. Other Guidelines, such as targets for adequacy of hemodialysis and peritoneal dialysis, serve as minimal standards of care for children with little supporting data specific to pediatrics. The importance of early referral and proactive care for children and adults with chronic renal failure is emphasized in all of the Guidelines. Optimum care should include early discussion of transplantation and choice of dialysis modality, preservation of sites for future vascular access, and early attention to anemia and nutrition. Clinical algorithms should be developed to implement the current Guidelines while data are generated to support modification of any of the recommendations for children.

Implementation of the Anemia Guidelines

Implementation of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Guidelines for the treatment of the anemia of chronic renal failure is a great challenge to all concerned with the improvement in the quality of life and survival of patients with chronic renal failure. These include physicians, nurses, technicians, dietitions, social workers, administrators, and private and public (Health Care Financing Administration) payers of the care. The principles of the process of implementation are reviewed and the barriers that can prevent implementation are discussed, showing how most of these can be overcome. Several of the more controversial Guidelines are discussed in detail, showing that with protocols that address the means for implementation, the goals of these Guidelines can be achieved.

Forum of the End-Stage Renal Disease Networks' Role in Implementing the National Kidney Foundation-Dialysis Outcomes Quality Initiative Clinical Practice Guidelines

The development and release of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Practice Guidelines marks an important step in the on-going process of improving the renal dialysis patient's outcomes. The Forum of End-Stage Renal Disease (ESRD) Networks' role in this process should be considered within the context of its mission and the ESRD Networks' Congressional mandate. In addition, facilitating the implementation of the NKF-DOQI Guidelines is one component of the Forum's current quality-related agenda. Environmental trends and current research indicate a variety of factors critical to the successful implementation of the NKF-DOQI Guidelines. The Forum's plan encompasses each of the following key elements: defining and evaluating the Guidelines and clinical performance measures (CPMs); prioritizing and locally disseminating NKF-DOQI Guidelines; converting NKF-DOQI Guidelines into CPMs; expanding the information infrastructure; and conducting quality activities and engaging local physicians. Keeping in mind the broader national agenda for quality improvement in the renal community, including continuing medical education programs focused on quality measurement and improvement tools and techniques, developing decision support tools and increasing on-line access to evidence-based reports and literature is important as well. Carrying out the Forum's plan for implementing the NKF-DOQI Guidelines, in collaboration with national nephrology professional and patient organizations, will facilitate Guideline adoption and use across the renal community.

The Cost of Implementing the Dialysis Outcomes Quality Initiative Clinical Practice Guidelines

for a clinical practice guideline to be accepted by the end-user, the system of reimbursement for the targeted service must be favorable. The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Guideline recommendations were developed without primary concern for the costs of their execution. Arguably, an unfavorable financial environment and excessive mercantile behavior by providers and payers would offer a considerable hindrance to their implementation. Toward addressing these concerns, three leaders in the development of the DOQI Guidelines for the Treatment of Anemia of Chronic Renal Failure, Hemodialysis Adequacy, and Vascular Access, have evaluated the hypothesis that implementing the recommendations of the DOQI Guidelines will increase the treatment costs for dialysis providers but will effect savings in the entire end-stage renal disease (ESRD) program. Their analyses suggest that under the current reimbursement system, this assumption may be true. However, restructured global reimbursement in the ESRD program will permit financial incentives for dialysis providers and the payer to coincide.