This new online series will feature questions and answers from NN&I authors and other renal professionals featured in the magazine. Next month we will discuss reducing hospitalization rates and preventing access failures.
This month NephrologyNews.com is featuring a Q&A with Daniel Coyne, MD, professor of medicine and director of hemodialysis at the Chromalloy American Kidney Center at Washington University in St. Louis. His article, “Why the FDA and CMS have it right (and how KDIGO got it wrong)” is featured in the February 2013 issue of Nephrology News & Issues.
Question: Do you think the common use of algorithms, especially among the large dialysis organizations, means some patients aren’t getting effective anemia treatment?
Answer: Recent algorithms I have seen reflect appropriate anemia treatment decisions. Less aggressive ESA use leads to lower hemoglobin in some patients, but is safer than overtreatment.
Q: Who tends to control anemia therapy: the nephrologist or the dialysis provider?
A: This differs among dialysis chains and facilities, but my recent experience has been chains are now sensitive to nephrologists deciding why anemia management in certain patients needs to differ from routine practice.
Q: Is individualized anemia treatment practical and possible in an environment where for-profits control the market and encourage efficiency over individualized therapy?
A: Yes, but in most patients it is unnecessary, as newer protocols are appropriate for a large majority of patients. Physicians are best equipped to identify exceptional situations where routine practice is not optimal, and consequently alter anemia treatment.
Q: Do you think the higher transfusion rate seen recently can be avoided?
A: No, nor should we look at transfusions rates in isolation. Trials have repeatedly shown patients receiving less ESA may or may not receive more transfusions, but they fare better than those aggressively treated with ESA. Advocates for reinstituting a hemoglobin floor have yet to demonstrate via trials that such a plan can safely reduce transfusions.