letter to the editor
cubilin/megalin-deficient mice is similar to the excretion rate of intact albumin in podocin-deficient mice,3 and he raises the question of the cause of hypoalbuminemia in the latter. First of all, we question Dr Comper’s attempt to estimate excretion rate of albumin fragments (mg/h) on the basis of measurements of urinary fragments (c.p.m.)2, as this relies on the assumption that the specific activity of the iodinated fragments and injected intact albumin is the same. Second, it is not clear how any conclusion as to the cause of hypoalbuminemia can be deduced from comparing excretion of fragments in one model with intact albumin in another. The renal albumin turnover is the sum of urinary albumin excretion and lysosomal degradation of endocytosed albumin in the proximal tubule. Dr Comper also suggests that the albumin we used was denatured causing excessive degradation and filtration of albumin fragments.2 We cannot exclude a difference in the degradation rate between labeled and unlabeled albumin; however, this does not change the important point that urinary excretion of albumin fragments is similar in wild types and in mice with abolished endocytosis. Thus, our studies do not provide any data on the absolute level of filtered albumin fragments in any of the mouse models nor do they show uptake of albumin fragments in the proximal tubule, and therefore Dr Comper’s extrapolation on our data appears to be purely speculative.
ensuring treatment quality was introduced in Portugal in 2008.2 As in the United States, the Portuguese flat rate includes additional components, such as laboratory and imaging tests, intradialytic intravenous antibiotics, and medication for the treatment of anemia, bone mineral disease, and nutrition and cardiovascular comorbidities. Vascular access management was added in 2011. Similarly, in Portugal, the capitated payment was progressively reduced over time, also because of cost pressure following the European economic crisis. Quality of care is closely monitored by sophisticated quality metrics including seven process indicators and two outcome indicators. As in Germany, Portuguese dialysis providers must disclose a complete quality assurance data set, and failure to meet quality requirements is penalized. A retrospective analysis of target achievements between 2008 and 2011 revealed a clear improvement in clinical outcomes coupled with cost reduction, mainly driven by containment of pharmaceutical costs. We agree with Kleophas et al.1 that better anemia control may reflect a higher dialysis dose. In Portugal, this was also facilitated by the general application of the technically advanced therapy on-line hemodiafiltration.3,4 In conclusion, both the German and the Portuguese experiences demonstrate that it is possible to maintain/improve the quality of care in a cost-containment environment. 1.
2. 1. 2.
3.
Comper WD. Is there equivalency of intact albuminuria and albumin peptideuria in nephrotic states? Kidney Int 2013; 84: 1050. Weyer K, Nielsen R, Christensen EI et al. Generation of urinary albumin fragments does not require proximal tubular uptake. J Am Soc Nephrol 2012; 23: 591–596. Nielsen R, Mollet G, Esquivel EL et al. Increased lysosomal proteolysis counteracts protein accumulation in the proximal tubule during focal segmental glomerulosclerosis. Kidney Int 2013; 84: 902–910.
1
1
Rikke Nielsen , Kathrin Weyer , Henrik Birn Erik I. Christensen1
1,2
and
1
Department of Biomedicine, Aarhus University, Aarhus, Denmark and Department of Nephrology, Aarhus Univeristy Hospital, Aarhus, Denmark Correspondence: Rikke Nielsen, Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark. E-mail: [email protected] 2
3.
4.
Kleophas W, Karaboyas A, Li Y et al. Changes in dialysis treatment modalities during institution of flat rate reimbursement and quality assurance programs. Kidney Int 2013; 84: 1051–1052. Ponce P, Marcelli D, Guerreiro A et al. Converting to a capitation system for dialysis payment – the Portuguese experience. Blood Purif 2012; 34: 313–324. Vaslaki L, Major L, Berta K et al. On-line haemodiafiltration versus haemodialysis: stable haematocrit with less erythropoietin and improvement of other relevant blood parameters. Blood Purif 2006; 24: 163–173. Locatelli F, Ho¨ rl WH. A step towards making online haemodiafiltration a gold standard. Nat Rev Nephrol 2013; 9: 316–318.
Daniele Marcelli1, Aileen Grassmann1 and Pedro Ponce2 1
Medical Board EMEALA, Fresenius Medical Care, Bad Homburg, Germany and NephroCare, Fresenius Medical Care, Lisbon, Portugal Correspondence: Aileen Grassmann, Medical Board EMEALA, Fresenius Medical Care, Bad Homburg, Germany. E-mail: [email protected]
2
Kidney International (2013) 84, 1051; doi:10.1038/ki.2013.311
Kidney International (2013) 84, 1050–1051; doi:10.1038/ki.2013.326
Changes in dialysis treatment modalities during institution of flat-rate reimbursement and quality assurance programs To the Editor: In their study, Kleophas et al.1 reported trends to improve quality metrics for hemodialysis in Germany even after the introduction of weekly flat-rate reimbursement. We would like to highlight that, besides the cited bundled prospective payment introduced in the United States in 2011, another initiative aiming to contain costs while concurrently Kidney International (2013) 84, 1047–1054
The Authors Reply: In their letter, Marcelli et al.1 reported on the quality of care and capitated payment in Portugal. These interesting findings corroborate our experience from Germany and also that from Japan2 and the United States.3,4 It can be assumed that international guidelines and key publications had a significant impact on the reported improvements and changes of dialysis practice patterns in the different countries. The results highlight our conclusion that further strategies for reimbursement policies should be designed to allow the freedom of treatment and quality assurance. 1.
Marcelli D, Grassmann A, Ponce P. Changes in dialysis treatment modalities during institution of flat-rate reimbursement and quality assurance programs. Kidney Int 2013; 84: 1051.
1051
cubilin/megalin-deficient mice is similar to the excretion rate of intact albumin in podocin-deficient mice,3 and he raises the question of the cause of hypoalbuminemia in the latter. First of all, we question Dr Comper’s attempt to estimate excretion rate of albumin fragments (mg/h) on the basis of measurements of urinary fragments (c.p.m.)2, as this relies on the assumption that the specific activity of the iodinated fragments and injected intact albumin is the same. Second, it is not clear how any conclusion as to the cause of hypoalbuminemia can be deduced from comparing excretion of fragments in one model with intact albumin in another. The renal albumin turnover is the sum of urinary albumin excretion and lysosomal degradation of endocytosed albumin in the proximal tubule. Dr Comper also suggests that the albumin we used was denatured causing excessive degradation and filtration of albumin fragments.2 We cannot exclude a difference in the degradation rate between labeled and unlabeled albumin; however, this does not change the important point that urinary excretion of albumin fragments is similar in wild types and in mice with abolished endocytosis. Thus, our studies do not provide any data on the absolute level of filtered albumin fragments in any of the mouse models nor do they show uptake of albumin fragments in the proximal tubule, and therefore Dr Comper’s extrapolation on our data appears to be purely speculative.
ensuring treatment quality was introduced in Portugal in 2008.2 As in the United States, the Portuguese flat rate includes additional components, such as laboratory and imaging tests, intradialytic intravenous antibiotics, and medication for the treatment of anemia, bone mineral disease, and nutrition and cardiovascular comorbidities. Vascular access management was added in 2011. Similarly, in Portugal, the capitated payment was progressively reduced over time, also because of cost pressure following the European economic crisis. Quality of care is closely monitored by sophisticated quality metrics including seven process indicators and two outcome indicators. As in Germany, Portuguese dialysis providers must disclose a complete quality assurance data set, and failure to meet quality requirements is penalized. A retrospective analysis of target achievements between 2008 and 2011 revealed a clear improvement in clinical outcomes coupled with cost reduction, mainly driven by containment of pharmaceutical costs. We agree with Kleophas et al.1 that better anemia control may reflect a higher dialysis dose. In Portugal, this was also facilitated by the general application of the technically advanced therapy on-line hemodiafiltration.3,4 In conclusion, both the German and the Portuguese experiences demonstrate that it is possible to maintain/improve the quality of care in a cost-containment environment. 1.
2. 1. 2.
3.
Comper WD. Is there equivalency of intact albuminuria and albumin peptideuria in nephrotic states? Kidney Int 2013; 84: 1050. Weyer K, Nielsen R, Christensen EI et al. Generation of urinary albumin fragments does not require proximal tubular uptake. J Am Soc Nephrol 2012; 23: 591–596. Nielsen R, Mollet G, Esquivel EL et al. Increased lysosomal proteolysis counteracts protein accumulation in the proximal tubule during focal segmental glomerulosclerosis. Kidney Int 2013; 84: 902–910.
1
1
Rikke Nielsen , Kathrin Weyer , Henrik Birn Erik I. Christensen1
1,2
and
1
Department of Biomedicine, Aarhus University, Aarhus, Denmark and Department of Nephrology, Aarhus Univeristy Hospital, Aarhus, Denmark Correspondence: Rikke Nielsen, Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark. E-mail: [email protected] 2
3.
4.
Kleophas W, Karaboyas A, Li Y et al. Changes in dialysis treatment modalities during institution of flat rate reimbursement and quality assurance programs. Kidney Int 2013; 84: 1051–1052. Ponce P, Marcelli D, Guerreiro A et al. Converting to a capitation system for dialysis payment – the Portuguese experience. Blood Purif 2012; 34: 313–324. Vaslaki L, Major L, Berta K et al. On-line haemodiafiltration versus haemodialysis: stable haematocrit with less erythropoietin and improvement of other relevant blood parameters. Blood Purif 2006; 24: 163–173. Locatelli F, Ho¨ rl WH. A step towards making online haemodiafiltration a gold standard. Nat Rev Nephrol 2013; 9: 316–318.
Daniele Marcelli1, Aileen Grassmann1 and Pedro Ponce2 1
Medical Board EMEALA, Fresenius Medical Care, Bad Homburg, Germany and NephroCare, Fresenius Medical Care, Lisbon, Portugal Correspondence: Aileen Grassmann, Medical Board EMEALA, Fresenius Medical Care, Bad Homburg, Germany. E-mail: [email protected]
2
Kidney International (2013) 84, 1051; doi:10.1038/ki.2013.311
Kidney International (2013) 84, 1050–1051; doi:10.1038/ki.2013.326
Changes in dialysis treatment modalities during institution of flat-rate reimbursement and quality assurance programs To the Editor: In their study, Kleophas et al.1 reported trends to improve quality metrics for hemodialysis in Germany even after the introduction of weekly flat-rate reimbursement. We would like to highlight that, besides the cited bundled prospective payment introduced in the United States in 2011, another initiative aiming to contain costs while concurrently Kidney International (2013) 84, 1047–1054
The Authors Reply: In their letter, Marcelli et al.1 reported on the quality of care and capitated payment in Portugal. These interesting findings corroborate our experience from Germany and also that from Japan2 and the United States.3,4 It can be assumed that international guidelines and key publications had a significant impact on the reported improvements and changes of dialysis practice patterns in the different countries. The results highlight our conclusion that further strategies for reimbursement policies should be designed to allow the freedom of treatment and quality assurance. 1.
Marcelli D, Grassmann A, Ponce P. Changes in dialysis treatment modalities during institution of flat-rate reimbursement and quality assurance programs. Kidney Int 2013; 84: 1051.
1051
