To the editor:
We fully respect the work accomplished by the Group of Quality Management of the SEN (1). However we would like to make some comments based on another interpretation of the available scientific information introduced in the article, as well as on our experience in the use of these quality indicators, which we measure at our Department since June of 2005.
1. Anemia indicators. In our experience it is not possible to achieve 90% of patients having an Hb value > 11 if one or both of the following conditions are not met: an important increase (> 15-20%) of the percent of patients having a blood Hb value of at least 13 g/dL, a limit that should not be exceeded according to the KDOQI guidelines (2007); or an Hb value > 12 g/dL in patients with underlying cardiovascular disease, as shown in the European guidelines for anemia management in patients with chronic renal disease (EBPG).3
Besides, the continuing efforts to achieve this objective increase the risk for a great variability in the hemoglobin.
We consider that this standard should be revaluated and perhaps a lower percentage could be established (about 80%). The percentage of patients that should not have an Hb value higher than 13 g/dL should also be taken into account.
2. Cardiovascular risk indicators. The KDOQI guidelines on osteodystrophy4 recommend monthly assessment of calcium, phosphorus, and PTH measurement quarterly.
With the introduction of the new chelating agents and calcium-mimicking agents, it is possible to control calcium and phosphorus levels and the calciumphosphorus product, as well as to improve the indicator percentages, according to the work of Arenas et al.5
That is not the case when an adequate control of PTH values (within the range 150-300 pg/mL) is tried.
We consider that indictor measurements of phosphorus and PTH should not be separately carried out, as both are related and are keystones when making important decisions about the therapies to be applied. We think that both parameters should be measured together quarterly.
3. Non-priority cardiovascular risk factors indicators. Both SEN6 and KDOQI (7) guidelines on cardiovascular risk recommend pre-dialysis blood pressure < 140/90 and post-dialysis blood pressure < 130/80.
Blood and pulse pressure values should be evaluated in patients in hemodialysis because they are predictors of cardiovascular morbimortality.6, 7 We do believe it is it is indicated to include adequate blood pressure and/or pulse pressure control among priority cardiovascular risk indicators. That further reinforces the efforts that we make during the whole pre-dialysis period, which has been shown to be very beneficial.
Guidelines, indicators and standards are instruments that the scientific evidence offers the physician to improve the patient¿s care. Individualization and common sense assure its quality.
