A systematic review of the cost-effectiveness of renal replacement therapies, and consequences for decision-making in the end-stage renal disease treatment pathway

Cost-effectiveness of daily home haemodialysis versus in-centre haemodialysis: A propensity score matching analysis based on real-world data from the French healthcare system

Background Daily home haemodialysis (HD) offers several advantages over conventional 3-times-weekly in-centre HD, with better preservation of quality of life and treatment flexibility, but its costs and potential benefits on mortality are poorly understood. Methods Individual healthcare data from the French National Health Data System for patients with end-stage kidney disease undergoing dialysis cross-referenced with the French National Cost Scale of the health ministry. After exclusion of patients treated < 90 days, and those without a treatment schedule or incomplete data for a social disadvantage score, 42 605 patients were selected (28 317 prevalent and 14 288 incident HD patients). After propensity score matching, 265 incident patients (in-centre HD, n = 212; daily home HD, n = 53) and 765 prevalent patients (in-centre HD, n = 612; daily home HD, n = 153) were analysed. Findings The global cost of daily home HD in incident patients was lower than in-centre HD (€1403/week vs. €1652/week, respectively). In prevalent patients, the cost was also slightly lower for daily home haemodialysis than compared to in-centre haemodialysis (€1360/week vs. €1456/week, respectively). The gross death rate in incident patients treated by in-centre HD after a 2-year follow-up was 10·4 % vs. 1·9 % for patients treated by daily home HD (p = 0·049, at Chi2 test; relative risk=5·5). Using a Cox proportional hazard regression model, in-centre HD was associated with a 7-fold higher risk of death (hazard ratio=7·888, p = 0·045). Interpretation Daily home HD is a more cost-effective and patient-centred treatment option than in-centre HD. Funding This research was funded by Physidia Ltd and Ramsay Health Care, France.

Efficacy of slow daily home hemodialysis with internal convection on removal of uremic toxins using the Physidia S3 monitor

Home hemodialysis, despite its recognized clinical benefits such as improved cardiac health and enhanced quality of life, remains underutilized worldwide. This study aims to evaluate the efficacy of home hemodialysis within slow daily dialysis programs, employing the Physidia S3 monitor. A prospective trial was conducted with 16 stable patients suffering from end-stage kidney disease and undergoing home hemodialysis. The study assessed the efficiency of slow daily short treatment dialysis using diverse criteria, including percent reduction, effective clearances, and solute mass removal, across a broad spectrum of uremic compounds, including sodium. Controlled sessions were implemented to replicate daily home treatment conditions. Selecting urea and ß2M as key biomarkers due to their associations with patient outcomes, our study achieved a standardized weekly Kt/V of 2.26 [1.99-2.70] and estimated kidney urea clearance of 11.4 [10.9-12.4] mL/min. ß2M mass removal per session was 146 mg, extrapolating to 707 (×5) and 845 (×6) mg weekly. Additionally, the time-averaged concentration of ß2M was maintained at 19.4 mg/L. The study also identified a net sodium mass removal of 126 mmol [98-182] or 7.4 g [5.8-10.7] NaCl per session. In conclusion, our findings suggest that slow daily, short treatment time, high flux hemodialysis, augmented by enhanced internal convective clearance, represents a highly efficient renal replacement modality on a weekly basis across large molecular weight uremic compounds. Moreover, the solute dialysate saturation coefficient emerges as a promising marker in slow-flow settings.

Machine learning models for predicting interaction affinity energy between human serum proteins and hemodialysis membrane materials

Membrane incompatibility poses significant health risks, including severe complications and potential fatality. Surface modification of membranes has emerged as a pivotal technology in the membrane industry, aiming to improve the hemocompatibility and performance of dialysis membranes by mitigating undesired membrane-protein interactions, which can lead to fouling and subsequent protein adsorption. Affinity energy, defined as the strength of interaction between membranes and human serum proteins, plays a crucial role in assessing membrane-protein interactions. These interactions may trigger adverse reactions, potentially harmful to patients. Researchers often rely on trial-and-error approaches to enhance membrane hemocompatibility by reducing these interactions. This study focuses on developing machine learning algorithms that accurately and rapidly predict affinity energy between novel chemical structures of membrane materials and human serum proteins, based on a molecular docking dataset. Various membrane materials with distinct characteristics, chemistry, and orientation are considered in conjunction with different proteins. A comparative analysis of linear regression, K-nearest neighbors regression, decision tree regression, random forest regression, XGBoost regression, lasso regression, and support vector regression is conducted to predict affinity energy. The dataset, comprising 916 records for both training and test segments, incorporates 12 parameters extracted from data points and involves six different proteins. Results indicate that random forest (R² = 0.8987, MSE = 0.36, MAE = 0.45) and XGBoost (R² = 0.83, MSE = 0.49, MAE = 0.49) exhibit comparable predictive performance on the training dataset. However, random forest outperforms XGBoost on the testing dataset. Seven machine learning algorithms for predicting affinity energy are analyzed and compared, with random forest demonstrating superior predictive accuracy. The application of machine learning in predicting affinity energy holds significant promise for researchers and professionals in hemodialysis. These models, by enabling early interventions in hemodialysis membranes, could enhance patient safety and optimize the care of hemodialysis patients.

The future of peritoneal dialysis

Peritoneal dialysis (PD), long established as the leading form of home dialysis, has comparatively good 5-year outcomes and cost-utility analyses have consistently demonstrated benefits to both patients and payers. Future improvements should still be sought, such as the further development of promising technologies designed to limit PD-associated harm, but given the physical and anatomical constraints of PD, these are unlikely to be transformational through the dialysis process itself. Rather, future focus should be on interventions that are effective across the whole dialysis population, such as mitigating the rate of loss in residual kidney function, pharmacological interventions for symptoms of kidney failure and suppressing inflammation. The greatest future challenge for the modality is inequity of access. In Europe, variation in PD uptake is >10-fold across the continent, with several contributing factors: differing economic drivers, variation in the empowerment of patients, physician attitudes and bias, small centre size, lack of experience, a nursing staff crisis, poor organizational culture and a lack of motivation and educational opportunities. It is time for a collective effort to address this and recently EuroPD convened a policy forum to initiate a multistakeholder approach to the problem, which extends to home haemodialysis. Use of PD worldwide is also highly variable, for some of the same reasons listed above, but with the additional challenges of the high cost of PD fluid and the lack of universal healthcare coverage. In the future, PD could and should play an important part in providing equitable access to dialysis worldwide, but to achieve this-and for the sake of the planet-point-of-care dialysis fluid generation would be transformative.

Therapeutic Potential of Oligo-Fucoidan in Mitigating Peritoneal Dialysis-Associated Fibrosis

Peritoneal dialysis (PD) serves as a home-based kidney replacement therapy with increasing utilization across the globe. However, long-term use of high-glucose-based PD solution incites repeated peritoneal injury and inevitable peritoneal fibrosis, thus compromising treatment efficacy and resulting in ultrafiltration failure eventually. In the present study, we utilized human mesothelial MeT-5A cells for the in vitro experiments and a PD mouse model for in vivo validation to study the pathophysiological mechanisms underneath PD-associated peritoneal fibrosis. High-glucose PD solution (Dianeal 4.25%, Baxter) increased protein expression of mesothelial-mesenchymal transition (MMT) markers, such as N-cadherin and α-SMA in MeT-5A cells, whereas it decreased catalase expression and stimulated the production of reactive oxygen species (ROS). Furthermore, macrophage influx and increased serum pro-inflammatory cytokines, such as IL-1β, MCP-1, and TNF-α, were observed in the PD mouse model. Interestingly, we discovered that oligo-fucoidan, an oligosaccharide extract from brown seaweed, successfully prevented PD-associated peritoneal thickening and fibrosis through antioxidant effect, downregulation of MMT markers, and attenuation of peritoneal and systemic inflammation. Hence, oligo-fucoidan has the potential to be developed into a novel preventive strategy for PD-associated peritoneal fibrosis.

Hemoincompatibility in Hemodialysis-Related Therapies and Their Health Economic Perspectives

Hemobiologic reactions associated with the hemoincompatibility of extracorporeal circuit material are an undesirable and inevitable consequence of all blood-contacting medical devices, typically considered only from a clinical perspective. In hemodialysis (HD), the blood of patients undergoes repetitive (at least thrice weekly for 4 h and lifelong) exposure to different polymeric materials that activate plasmatic pathways and blood cells. There is a general agreement that hemoincompatibility reactions, although unavoidable during extracorporeal therapies, are unphysiological contributors to non-hemodynamic dialysis-induced systemic stress and need to be curtailed. Strategies to lessen the periodic and direct effects of blood interacting with artificial surfaces to stimulate numerous biological pathways have focused mainly on the development of 'more passive' materials to decrease intradialytic morbidity. The indirect implications of this phenomenon, such as its impact on the overall delivery of care, have not been considered in detail. In this article, we explore, for the first time, the potential clinical and economic consequences of hemoincompatibility from a value-based healthcare (VBHC) perspective. As the fundamental tenet of VBHC is achieving the best clinical outcomes at the lowest cost, we examine the equation from the individual perspectives of the three key stakeholders of the dialysis care delivery processes: the patient, the provider, and the payer. For the patient, sub-optimal therapy caused by hemoincompatibility results in poor quality of life and various dialysis-associated conditions involving cost-impacting adjustments to lifestyles. For the provider, the decrease in income is attributed to factors such as an increase in workload and use of resources, dissatisfaction of the patient from the services provided, loss of reimbursement and direct revenue, or an increase in doctor-nurse turnover due to the complexity of managing care (nephrology encounters a chronic workforce shortage). The payer and healthcare system incur additional costs, e.g., increased hospitalization rates, including intensive care unit admissions, and increased medications and diagnostics to counteract adverse events and complications. Thus, hemoincompatibility reactions may be relevant from a socioeconomic perspective and may need to be addressed beyond just its clinical relevance to streamline the delivery of HD in terms of payability, future sustainability, and societal repercussions. Strategies to mitigate the economic impact and address the cost-effectiveness of the hemoincompatibility of extracorporeal kidney replacement therapy are proposed to conclude this comprehensive approach.

Center Hemodialysis Versus Peritoneal Dialysis: A Cost-Utility Analysis

Introduction Kidney replacement therapy (KRT) is needed for patients with end-stage kidney disease. While it is clear that kidney transplantation remains the gold standard in KRT, data comparing the cost-utility of peritoneal dialysis (PD) and hemodialysis (HD) are scarce. No such analysis has been performed for German patients.  Methods We used aggregated data generated by the Short Form 36 Health Survey (SF-36) for quality of life and insurance claims to evaluate mortality and economic impact. Quality-adjusted life years (QALY) and cost-utility were calculated accordingly.  Results PD is superior to HD within all dimensions of the SF-36, both in terms of QALY and cost-utility. The difference in cost per QALY between the aggregated physical dimensions (€50,671.54 vs. €39,745.77) is greater than that of the aggregated mental dimensions (€31,638.75 vs. €25,287.63). However, there is considerable variability among patients.  Conclusion From a health-economic point of view, PD should be preferred over HD when deciding on the KRT modality for the patient. This is not reflected in current practice, though. However, interindividual differences and patient preferences should be considered in the decision.

Cost-effectiveness of dialysis and kidney transplantation to treat end-stage renal disease in Ukraine

OBJECTIVE

Aim: To determine the economic feasibility of using kidney transplantation compared to hemodialysis in end-stage renal disease in the long term in countries with a low and medium level of economic development using the example of Ukraine.

PATIENTS AND METHODS

Materials and Methods: The cost effectiveness analysis method was used. Conducted Markov modeling and comparison of the consequences of kidney transplantation and hemodialysis in terms of treatment costs and the number of added years of life for a cohort of 1,675 patients were carried out. The incremental cost-effectiveness ratio is defined.

RESULTS

Results: Based on the results of modeling, it was determined that among 1,675 patients with end-stage kidney disease in Ukraine, 1,248 (74.5%) will remain alive after 10 years of treatment when kidney transplantation technology is used. The highest costs will be in the first year ($25,864), and in subsequent years - about $5,769. With the use of hemodialysis technology, only 728 patients (43.5%) will be alive after 10 years, the cost of treating one patient per year is $11,351. The use of kidney transplantation adds 3191 years of quality life for 1675 patients compared with hemodialysis (1.9 years per patient).

CONCLUSION

Conclusions: Kidney transplantation is an economically feasible technology for Ukraine, as the incremental cost-effectiveness ratio is $4694, which is 1.04 times higher than Ukraine's GDP per capita. The results of the study allow us to recommend that decision-makers in countries with a low and medium level of economic development give priority in financing to renal transplantation.