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To the Editor: Anemia management in patients with chronic kidney disease has come under increasing scrutiny from the scientific community, Congress, the Food and Drug Administration, the Centers for Medicare & Medicaid Services, and the public. At issue is whether current utilization of the highly effective, but expensive, erythropoiesis-stimulating agents (ESAs) is driven primarily by clinical or by financial motives. The study by Dr Thamer and colleagues¹ suggests the latter, and the Editorial by Dr Coyne² challenges the integrity of nephrologists who manage this difficult and complex patient population.

Thamer et al performed an observational study using Medicare claims data and concluded that large for-profit chains administered higher epoetin doses and "reimbursement policy and clinical performance measures may provide incentives for dialysis facilities . . . to target hematocrit levels exceeding those recommended by the clinical guidelines."¹ The authors imply that the facility controls dosing for ESAs, whereas it is the nephrologist, weighing the . . . [Full Text of this Article]

Alan S. Kliger, MD
akliger@srhs.org
Department of Medicine
Hospital St Raphael
New Haven, Connecticut

Allen R. Nissenson, MD
Department of Medicine
David Geffen School of Medicine
Los Angeles, California

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Epoetin Dosing and Dialysis Facility Ownership—Reply
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Epoetin Dosing and Dialysis Facility Ownership—Reply
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Use of Epoetin in Chronic Renal Failure
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