To the Editor: In the article by Harris et al and the accompanying editorial by Manns and Quinn, there is no mention of the financial motivation to start dialysis therapy early. In the United States, partial ownership of dialysis centers through joint ventures is common. There is a distinct financial benefit to "keep the center full" and place patients on dialysis therapy irrespective of what is in the patient's best interests. In addition to the ownership issue, having a large number of dialysis patients increases the income of the nephrolo-gist. Reimbursement for dialysis visits is greater than for office visits. Moreover, one can see many patients in a sitting, again increasing one's income. With minimal oversight of who is placed on dialysis therapy, such a system is ripe for abuse. Filling out the 2728 form appears to be more of a formality than producing a document that is reviewed and analyzed for appropriate criteria. It also is possible that classification of chronic kidney disease into 5 stages has contributed to this. If a patient is in stage 5, starting dialysis therapy can be justified with minimal need for documentation. A more robust system should be introduced such that patients who are started on dialysis therapy truly need such a life-changing therapy. Rather than starting dialysis therapy at an arbitrary glomer-ular filtration rate, the decision to place a patient on dialysis therapy should take into account a number of other factors, as recently outlined by Rosansky et al.
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