OH

Comment on Federal Register 77:133 July 11, 2012 Part II 42 CFR parts 413 and 417 III.C.3.a.iii. NQF #1423: Minimum spKt/V for pediatric hemodialysis This proposed measure is intended to assess the adequacy of hemodialysis in children. It differs in two important ways from the measures adopted to assess the adequacy of dialysis in adults. Unlike the comparable measure in adults, the proposed measure does not exclude those with significant residual kidney (renal) function (RKF or RRF), and the measure applies to children who are treated with hemodialysis four days a week rather than just three days a week. These differences raise concern. The argument for adopting the new pediatric measure (with these two differences) does not meet the evidence-based standards of NQF. It is acknowledged in NQF #1423 that there is no evidence to support a lower dose of dialysis in children than in adults and insufficient evidence to support a higher dose. Adoption of the proposed measure would, in effect, raise the dialysis dose above the adult dose in a substantial number of children who either have a significant RKF or are treated with dialysis four days a week. The reasons for prescribing dialysis four days a week would seem important in deciding to group these children along with those who receive dialysis three days a week. Unfortunately, the data has not been teased apart to explain why so many children receive frequent dialysis. One possible reason, which is based on personal experience, is to help manage fluids and to control hypertension. More frequent dialysis in this situation would mean that the dialysis dose on the day of dialysis could be reduced while still being able to provide an adequate weekly dose. This sort of calculated delivery of dialysis could also explain the prevalence of low spKt/V in children. To include all those who receive four a week dialysis in the quality initiative, it may be necessary to adopt a measure of adequacy that is based on weekl