Design and methods of a strategic outcome study for chronic kidney disease: Frontier of Renal Outcome Modifications in Japan

Effective method for life-style modifications focused on dietary sodium intake in chronic kidney disease: sub-analysis of the FROM-J study

BACKGROUND

Lifestyle modifications by educational sessions are an important component of multidisciplinary treatment for chronic kidney disease (CKD). We attempted to identify the best method to teach these modifications in order to ensure their acceptance by patients and investigated its effectiveness in CKD practice.

METHODS

This study is a post-hoc analysis of the FROM-J study. Subjects were 876 CKD patients in the advanced care group of the FROM-J study who had received lifestyle modification sessions every 3 months for 3.5 years. Two-hundred and ten males (32.6%) and 89 females (38.2%) showed success in sodium restriction. In this study, we examined factors affecting sodium restriction in these subjects.

RESULTS

Subjects received three or more consecutive educational sessions about improvement of salt intake. The median salt-intake improvement maintenance period was 407 days. The number of dietary counseling sessions (OR 1.090, 95%CI: 1.012-1.174) in males and the number of dietary counseling sessions (OR 1.159, 95%CI: 1.019-1.318), CKD stage progression (OR 1.658, 95%CI: 1.177-2.335), and collaboration with a nephrologist (OR 2.060, 95%CI: 1.073-3.956) in females were identified as significant factors improving salt intake. The only factor contributing to the maintenance of improved salt intake was the continuation of dietary counseling (p = 0.013).

CONCLUSION

An increased number of educational sessions was the only successful approach for males to implement and maintain an improved salt intake. Providing the resources for continuous counseling is beneficial for lifestyle modifications and their maintenance in the long-term management of CKD. Continuous counseling for lifestyle modifications is highly cost-effective.

TRIAL REGISTRATION

The FROM-J study was registered in UMIN000001159 on 16/05/2008.

Temporal trends in prevalence and disability of chronic kidney disease caused by specific etiologies: an analysis of the Global Burden of Disease Study 2019

BACKGROUND

The prevalence of disability in CKD is high. In this context the aim of the present study was to assess the  temporal trends of prevalence and disability progression for chronic kidney disease (CKD) caused by specific etiologies.

METHODS

Using data from the Global Burden of Diseases Study (GBD) 2019, we examined the age-standardized rates of CKD prevalence and disability-adjusted life-years for different etiologies, including Type 1/2 diabetes mellitus (T1DM/T2DM), glomerulonephritis, and hypertension. We also calculated the average annual percentage changes to assess trends. Additionally, we utilized the joinpoint regression model to identify significant shifts over time.

RESULTS

From 1990 to 2019, the global prevalence of CKD due to various etiologies exhibited an overall increasing trend, albeit with fluctuations. Notably, CKD due to T1DM, glomerulonephritis, and hypertension consistently demonstrated a significant upward trend across all continents, while the prevalence of CKD due to T2DM varied across continents. In terms of disability-adjusted life-years, CKD due to T2DM and hypertension exhibited a significant rising trend over the past 30 years. However, changes in age standardized disability-adjusted life-years for CKD due to different etiologies were not consistent across continents, with an upward trend observed in The Americas and a contrasting trend in Asia. Furthermore, both age-standardized prevalence rate and age standardized disability-adjusted life-year trends for CKD varied significantly across 204 countries and territories. Additionally, a negative association was observed between the Socio-demographic Index and the disability progression of CKD.

CONCLUSION

The prevalence and disability burden of CKD caused by specific etiologies show substantial heterogeneity worldwide, highlighting significant disparities in the distribution of CKD. It is crucial to implement geographic and personalized strategies in different regions to alleviate the burden of CKD effectively.

Long-term effectiveness of a primary care practice facilitation program for chronic kidney disease management: an extended follow-up of a cluster-randomized FROM-J study

BACKGROUND

Practice facilitation program by multidisciplinary care for primary care physicians (PCPs) is expected to improve chronic kidney disease (CKD) outcomes, but there is no clear evidence of its long-term effectiveness. We have previously performed a cluster-randomized controlled trial for 3.5 years (the Frontier of Renal Outcome Modifications in Japan (FROM-J) study) with two arms-group A without the program and group B with the program. We aimed to assess the long-term effectiveness of the practice facilitation program on CKD outcomes via an extended 10-year follow-up of the FROM-J study.

METHODS

We enrolled patients who were in the FROM-J study. The primary composite endpoint comprised cardiovascular disease (CVD), renal replacement therapy initiation and a 50% decrease in the estimated glomerular filtration rate (eGFR). The secondary endpoints were survival rate, eGFR decline rate and collaboration rate between PCPs and nephrologists.

RESULTS

The occurrence of the primary composite endpoint tended to be lower in group B (group A: 27.1% versus group B: 22.1%, P = 0.051). Furthermore, CVD incidence was remarkably lower in group B (group A: 10.5% versus group B: 6.4%, P = 0.001). Although both mortality and the rate of eGFR decline were identical between both groups, the eGFR decline rate was significantly better in group B than in group A only in patients with stage G3a at enrollment (group A: 2.35 ± 3.87 mL/min/1.73 m2/year versus group B: 1.68 ± 2.98 mL/min/1.73 m2/year, P = 0.02). The collaboration rate was higher in group B.

CONCLUSIONS

The CKD practice facilitation program for PCPs reliably decreases CVD events and may reduce the progression of cases to end-stage kidney disease.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

Health-related behavioral changes and incidence of chronic kidney disease: The Japan Specific Health Checkups (J-SHC) Study

The transtheoretical model (TTM) is a commonly used model of health-related behavioral change. However, the practical effect of using this model for chronic kidney disease (CKD) self-management remains unclear. This study aimed to investigate the association between stages of change for lifestyle behavior and the incidence of CKD in the general Japanese population. A retrospective cohort study was conducted among 178,780 non-CKD participants aged 40–74 years who underwent annual health check-ups for two consecutive years between 2008 and 2009. Health behavior change was determined using questionnaires based on the TTM, which consists of five stages of change (precontemplation, contemplation, preparation, action, and maintenance). The exposure of interest was the change in stages between two years. Participants were categorized into 3 groups ‘improved’, ‘unchanged’, or ‘deteriorated’. The association between the change in stages and the incidence of CKD was examined using logistic regression analysis. After one year of follow-up, 20.0% of participants developed CKD. Participants in the deteriorated group showed a significantly higher risk of CKD incidence than in the improved group. Promoting the stage of change for healthy lifestyle behaviors evaluated by the TTM was associated with a risk reduction for the incidence of CKD.

Behaviour modification intervention for patients with chronic kidney disease could provide a mid- to long-term reduction in public health care expenditure: budget impact analysis

BACKGROUND

A recent cost-effectiveness analysis (CEA) study evaluated the widespread diffusion of behaviour modification intervention for patients with chronic kidney disease (CKD). Incorporating this behaviour modification intervention, comprising educational sessions on nutrition/lifestyle and support for regular patient visits, to the current CKD guideline-based practice was found to be cost-effective. This study aimed to examine the affordability of this efficient new practice under the hypothesis that the behaviour modification intervention would be initiated by general physicians (GPs).

METHODS

A budget impact analysis was conducted by defining the target population as patients aged 40-74 years with stage-3-5 CKD based on the prevalence of definitive CKD in the Japanese general population. Costs expended by social insurers without discount were counted as budgets. We estimated the annual budget impact for 15 years by running our CEA model, assuming that it would be good for the span.

RESULTS

We estimated the number of patients with end-stage kidney disease (ESKD) to decrease by 4,496 in the fifteenth year of the new practice using our CEA model. Compared to that in the current practice, the budget impact as total additional expenditure of the new practice was estimated to be negative by the tenth year in the base case.

CONCLUSIONS

The widespread diffusion of behaviour modification intervention would contain public health care expenditure over the mid-to-long term, resulting from a reduction in progression to ESKD. We suggest that providing sufficient economic incentives to GPs and strengthening recommendations in CKD guidelines would realise effective GP-initiated interventions.

Association of blood pressure and renal outcome in patients with chronic kidney disease; a post hoc analysis of FROM-J study

It is well-known that hypertension exacerbates chronic kidney disease (CKD) progression, however, the optimal target blood pressure (BP) level in patients with CKD remains unclear. This study aimed to assess the optimal BP level for preventing CKD progression. The risk of renal outcome among different BP categories at baseline as well as 1 year after, were evaluated using individual CKD patient data aged between 40 and 74 years from FROM-J [Frontier of Renal Outcome Modifications in Japan] study. The renal outcome was defined as ≥ 40% reduction in estimated glomerular filtration rate to < 60 mL/min/1.73 m², or a diagnosis of end stage renal disease. Regarding baseline BP, the group of systolic BP (SBP) 120-129 mmHg had the lowest risk of the renal outcome, which increased more than 60% in SBP ≥ 130 mmHg group. A significant increase in the renal outcome was found only in the group of diastolic BP ≥ 90 mmHg. The group of BP < 130/80 mmHg had a benefit for lowering the risk regardless of the presence of proteinuria, and it significantly reduced the risk in patients with proteinuria. Achieving SBP level < 130 mmHg after one year resulted in a 42% risk reduction in patients with SBP level ≥ 130 mmHg at baseline. Targeting SBP level < 130 mmHg would be associated with the preferable renal outcome.Clinical Trial Registration-URL: https://www.umin.ac.jp/ctr/ . Unique identifier: UMIN000001159 (16/05/2008).

A practical approach of salt and protein restriction for CKD patients in Japan

Dietary management, in particular salt and protein restriction is fundamental for the proper care of CKD patients. Therefore, a practical guide to the dietary treatment may be helpful among progressive CKD patients. In Japan, two academic societies such as Japanese Society of Nephrology and Japanese Society for Dialysis Therapy have recently published Guidelines for Dietary Management for non-dialysis dependent CKD and dialysis-dependent CKD, respectively.In this manuscript, we summarized the practical guide for salt and protein restriction from the Japanese Society of Nephrology to retard the progression of CKD to endstage renal disease. This guide will promote further the collaboration of Nephrologists and Dietitians.

Evaluation of the Validity of a Novel CKD Assessment Checklist Used in the Frontier of Renal Outcome Modifications in Japan Study

OBJECTIVE

This study aimed to assess the validity of a novel chronic kidney disease (CKD) evaluation checklist method used in the Frontier of Renal Outcome Modifications in Japan study.

METHODS

Nineteen patients with CKD were recruited, and each patient was assessed by 2 dietitians using the checklist and provided with lifestyle modification instructions based on their assessment. We evaluated the concordance between dietitians, and we assessed the accuracy of the protein and salt intake estimates made by dietitians who only had access to patients' food diaries and verbal reports through comparison with assessments made by an independent dietitian who additionally had access to patients' meal photographs and urine collections.

RESULTS

The most frequently given instructions concerned blood pressure control (46%), followed by body mass index control (28%), and potassium control (9%). The instructions provided to patients corresponded between dietitians at rates of 94% for patients' 1st evaluation and 74% for their 2nd evaluation. The evaluated items showed good agreement between dietitians except for their estimates of salt and protein intakes. The dietitians categorized salt and protein intakes into 3 groups each (<6, 6-12, and >12 g and <0.8, 0.8-1.2, and >1.2 g/kg, respectively). The concordance rates between dietitians were 77.1% and 80.8%, and Cohen's κ coefficients were 0.633 and 0.613 for salt and protein intakes, respectively. The concordance rates between the dietitians' estimates and the independent dietitian's objective assessment were 78.5% and 45.1%, and Cohen's κ coefficients were 0.616 and 0.311 for salt and protein intakes, respectively. The estimates and objective assessments were strongly correlated for salt intake, but weakly correlated for protein intake.

CONCLUSION

We concluded that the checklist method was appropriate for the evaluation of CKD patients except for protein intake estimation. We hope it will be useful for the instruction of CKD patients widely in the future.

Effect of Behavior Modification on Outcome in Early- to Moderate-Stage Chronic Kidney Disease: A Cluster-Randomized Trial

OBJECTIVES

Owing to recent changes in our understanding of the underlying cause of chronic kidney disease (CKD), the importance of lifestyle modification for preventing the progression of kidney dysfunction and complications has become obvious. In addition, effective cooperation between general physicians (GPs) and nephrologists is essential to ensure a better care system for CKD treatment. In this cluster-randomized study, we studied the effect of behavior modification on the outcome of early- to moderate-stage CKD.

DESIGN

Stratified open cluster-randomized trial.

SETTING

A total of 489 GPs belonging to 49 local medical associations (clusters) in Japan.

PARTICIPANTS

A total of 2,379 patients (1,195 in group A (standard intervention) and 1,184 in group B (advanced intervention)) aged between 40 and 74 years, who had CKD and were under consultation with GPs.

INTERVENTION

All patients were managed in accordance with the current CKD guidelines. The group B clusters received three additional interventions: patients received both educational intervention for lifestyle modification and a CKD status letter, attempting to prevent their withdrawal from treatment, and the group B GPs received data sheets to facilitate reducing the gap between target and practice.

MAIN OUTCOME MEASURE

The primary outcome measures were 1) the non-adherence rate of accepting continuous medical follow-up of the patients, 2) the collaboration rate between GPs and nephrologists, and 3) the progression of CKD.

RESULTS

The rate of discontinuous clinical visits was significantly lower in group B (16.2% in group A vs. 11.5% in group B, p = 0.01). Significantly higher referral and co-treatment rates were observed in group B (p<0.01). The average eGFR deterioration rate tended to be lower in group B (group A: 2.6±5.8 ml/min/1.73 m2/year, group B: 2.4±5.1 ml/min/1.73 m2/year, p = 0.07). A significant difference in eGFR deterioration rate was observed in subjects with Stage 3 CKD (group A: 2.4±5.9 ml/min/1.73 m2/year, group B: 1.9±4.4 ml/min/1.73 m2/year, p = 0.03).

CONCLUSION

Our care system achieved behavior modification of CKD patients, namely, significantly lower discontinuous clinical visits, and behavior modification of both GPs and nephrologists, namely significantly higher referral and co-treatment rates, resulting in the retardation of CKD progression, especially in patients with proteinuric Stage 3 CKD.

TRIAL REGISTRATION

The University Hospital Medical Information Network clinical trials registry UMIN000001159.

Prevalence and incidence of chronic kidney disease stage G5 in Japan

The prevalence and incidence of end-stage kidney disease (ESKD) have continued to increase worldwide. Japan was known as having the highest prevalence of ESKD in the world; however, Taiwan took this place in 2001, with the USA still in third position. However, the prevalence data from Japan and Taiwan consisted of dialysis patients only. The prevalence and incidence of Kidney Transplantation (KT) in Japan were quite low, and the number of KT patients among those with ESKD was regarded as negligibly small. However, the number of KT recipients has increased recently. Furthermore, there are no reports about nationwide surveys on the prevalence and incidence of predialysis chronic kidney failure patients in Japan. This review describes our recent study on the estimated number of chronic kidney disease (CKD) stage G5 patients and the number of ESKD patients living in Japan, obtained via the cooperation of five related medical societies. From the results, as of Dec 31, 2007, 275,242 patients had received dialysis therapy and 10,013 patients had a functional transplanted kidney, and as of Dec 31, 2008, 286,406 patients had received dialysis therapy and 11,157 patients had a functional transplanted kidney. Consequently, there were 285,255 patients with CKD who reached ESKD and were living in Japan in 2008 and 297,563 in 2009. We also estimated that there were 67,000 predialysis CKD stage G5 patients in 2009, 37,365 patients introduced to dialysis therapy, and 101 patients who received pre-emptive renal transplantation in this year. In total, there were 37,466 patients who newly required renal replacement therapy (RRT) in 2009. Not only the average ages, but also the primary renal diseases of the new ESKD patients in each RRT modality were different.

Budget impact analysis of chronic kidney disease mass screening test in Japan

Background

Our recently published cost-effectiveness study on chronic kidney disease mass screening test in Japan evaluated the use of dipstick test, serum creatinine (Cr) assay or both in specific health checkup (SHC). Mandating the use of serum Cr assay additionally, or the continuation of current policy mandating dipstick test only was found cost-effective. This study aims to examine the affordability of previously suggested reforms.

Methods

Budget impact analysis was conducted assuming the economic model would be good for 15 years and applying a population projection. Costs expended by social insurers without discounting were counted as budgets.

Results

Annual budget impacts of mass screening compared with do-nothing scenario were calculated as ¥79–¥−1,067 million for dipstick test only, ¥2,505–¥9,235 million for serum Cr assay only and ¥2,517–¥9,251 million for the use of both during a 15-year period. Annual budget impacts associated with the reforms were calculated as ¥975–¥4,129 million for mandating serum Cr assay in addition to the currently used mandatory dipstick test, and ¥963–¥4,113 million for mandating serum Cr assay only and abandoning dipstick test.

Conclusions

Estimated values associated with the reform from ¥963–¥4,129 million per year over 15 years are considerable amounts of money under limited resources. The most impressive finding of this study is the decreasing additional expenditures in dipstick test only scenario. This suggests that current policy which mandates dipstick test only would contain medical care expenditure.

Nephrology for the people: Presidential Address at the 42nd Regional Meeting of the Japanese Society of Nephrology in Okinawa 2012

The social and economic burdens of dialysis are growing worldwide as the number of patients increases. Dialysis is becoming a heavy burden even in developed countries. Thus, preventing end-stage kidney disease is of the utmost importance. Early detection and treatment is recommended because late referral is common, with most chronic kidney disease (CKD) patients remaining asymptomatic until a late stage. Three-quarters of dialysis patients initiated dialysis therapy within 1 year after referral to the facility. Since its introduction in 2002, the definition of CKD has been widely accepted not only by nephrologists but also by other medical specialties, such as cardiologists and general practitioners. Japan has a long history of general screening for school children, university students, and employees of companies and government offices, with everybody asked to participate. The urine test for proteinuria and hematuria is popular among Japanese people; however, the outcomes have not been well studied. We examined the effects of clinical and laboratory data from several sources on survival of dialysis patients and also predictors of developing dialysis from community-based screening (Okinawa Dialysis Study, OKIDS). At an early CKD stage, patients are usually asymptomatic; therefore, regular health checks using a urine dipstick and serum creatinine are recommended. The intervals for follow-up, however, are debatable due to the cost. CKD is a strong risk factor for developing cardiovascular disease and death and also plays an important role in infection and malignancies, particularly in elderly people. People can live longer with healthy kidneys.

Effect of glomerular filtration rate and proteinuria on medical cost among screened subjects

BACKGROUND

Chronic kidney disease is a predictor of end-stage renal disease (ESRD) and cardiovascular disease (CVD). Therefore, the medical expenses are higher with the decrease in glomerular filtration rate (GFR). However, few studies have examined the medical expenses according to the baseline GFR.

METHODS

We investigated the relationship between GFR at health checks and medical expenses, combining the registries of both the health checks and report of medical expenses (receipts). The health checks were done from April 2008 to March 2009, and the eligible subjects were covered by the Okinawa Branch of the Japan Health Insurance Association. All reports of medical expenses were reviewed from April 2008 to March 2010 (24 months).

RESULTS

A total of 74,354 subjects, 38.2 % females with the mean age of 48.1 years, were examined according to whether they had visited medical facilities during the study period. The total number of receipts was 773,276. The average receipt point, 1 point = 10 Yen, was 686,410 (eGFR < 15), 56,408 (eGFR 15-29), 47,263 (eGFR 30-44), 24,372 (45-59), 16,018 (eGFR 60-74), 13,893 (eGFR 75-89), 13,990 (eGFR 90-104), 14,717 (eGFR 105-119), and 19,139 (eGFR 120 and over), respectively. The relationship between eGFR and medical expense was U-shaped, and the expense was lowest at eGFR 75-89.

CONCLUSION

We demonstrate that the medical expenses increase as eGFR decreases. Subjects with higher eGFR, 120 and over, seemed to have higher medical expenses.

Cost-effectiveness of chronic kidney disease mass screening test in Japan

BACKGROUND

Chronic kidney disease (CKD) is a significant public health problem. Strategy for its early detection is still controversial. This study aims to assess the cost-effectiveness of population strategy, i.e. mass screening, and Japan's health checkup reform.

METHODS

Cost-effectiveness analysis was carried out to compare test modalities in the context of reforming Japan's mandatory annual health checkup for adults. A decision tree and Markov model with societal perspective were constructed to compare dipstick test to check proteinuria only, serum creatinine (Cr) assay only, or both.

RESULTS

Incremental cost-effectiveness ratios (ICERs) of mass screening compared with do-nothing were calculated as ¥1,139,399/QALY (US $12,660/QALY) for dipstick test only, ¥8,122,492/QALY (US $90,250/QALY) for serum Cr assay only and ¥8,235,431/QALY (US $91,505/QALY) for both. ICERs associated with the reform were calculated as ¥9,325,663/QALY (US $103,618/QALY) for mandating serum Cr assay in addition to the currently used mandatory dipstick test, and ¥9,001,414/QALY (US $100,016/QALY) for mandating serum Cr assay and applying dipstick test at discretion.

CONCLUSIONS

Taking a threshold to judge cost-effectiveness according to World Health Organization's recommendation, i.e. three times gross domestic product per capita of ¥11.5 million/QALY (US $128 thousand/QALY), a policy that mandates serum Cr assay is cost-effective. The choice of continuing the current policy which mandates dipstick test only is also cost-effective. Our results suggest that a population strategy for CKD detection such as mass screening using dipstick test and/or serum Cr assay can be justified as an efficient use of health care resources in a population with high prevalence of the disease such as in Japan and Asian countries.

Role of chronic kidney disease in cardiovascular disease: are we different from others?

The incidence and prevalence of chronic dialysis patients in Japan is increasing linearly and is currently as high as 300 and 2300 per million population, respectively. The incidence of end-stage renal disease is closely related to that of chronic dialysis; findings which are captured in detail in the Japanese Society for Dialysis Therapy registry. Life expectancy of dialysis patients is poor compared to the age- and sex-matched general population, and is equivalent to that of an 80-year-old man or an 87-year-old woman, i.e., dialysis patients seem 15-18 years older than their actual age. Cardiac death is the leading cause of death; however, death due to stroke and acute myocardial infarction is decreasing. The annual mortality rate is 6.5% among the dialysis population. For the past 10 years, the mortality risk has remained high despite the avoidance of blood transfusions by the administration of erythropoiesis-stimulating agents, the use of renin-angiotensin system inhibitors, and improvements in general medical care. Several studies have confirmed the significance of chronic kidney disease (CKD) on the development of cardiovascular disease (CVD) and mortality; the lower the estimated glomerular filtration rate (eGFR), the higher the incidence of CVD. The cut-off levels for eGFR are not yet clear. CKD is an important predictor of CVD in Japan, similar to other parts of the world. Strategies for early detection of CKD are needed because, in many cases, CKD remains asymptomatic until late stages. Timely treatment for CKD is necessary to minimize costs for unnecessary care and testing. Unless CDK is properly managed, it will not be possible to maintain quality and longevity of life. The Japanese population is rapidly aging and will have the largest proportion of elderly people in the world. A systematic strategy for managing CKD patients is warranted.