The Cost Effectiveness of High-Dose versus Conventional Haemodialysis: a Systematic Review

Effectiveness of Implantable Doppler Probe Versus Standard Clinical Care in Preventing Thrombosis-Related Graft Loss in Kidney Transplantation: A Systematic Review and Meta-Analysis

OBJECTIVES

The implantable Doppler probe can monitor the patency of vascular anastomosis, thereby facilitating early detection of vascular thrombosis critical to reducing graft loss. In this study, we examined the effectiveness of this technology compared with standard clinical care in reducing thrombosis-related graft loss and the requirement for color duplex ultrasonography in the first 24 hours postoperatively by a medical literature search of the application of this technology in kidney transplantation.

MATERIALS AND METHODS

We conducted a systematic search (January 15, 2024) of a wide range of experimental and observational studies that comprised kidney transplant recipients monitored with blood flow sensing technology (intervention group) and standard clinical care (control group). Primary outcomes were differences between groups of thrombosis-related graft loss and surveillance requirement of color duplex ultrasonography scans in the first 24 hours postoperatively. Two independent researchers conducted critical appraisal and data extraction of the selected papers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. We used a random effects model for the meta-analysis. Dichotomous outcomes were expressed as relative risk or odds ratio.

RESULTS

The search identified 43 articles. After exclusion criteria, 7 studies (1 experimental, 6 observational) were included, with a total participant sample of 874 adult kidney transplant recipients with and without blood flow sensing technology. The certainty of evidence level was rated as moderate. Blood flow sensing technology resulted in a 66% reduction in the risk of thrombosis-related graft loss and a 61% lower probability of requiring color duplex ultrasonography in the first 24 hours postoperatively compared with standard clinical care.

CONCLUSIONS

Blood flow sensing technology can be used as a helpful adjunct in the postoperative monitoring of kidney transplant recipients. However, given the technical limitations, signals should be interpreted alongside the traditional clinical assessment techniques.

A Study Protocol Exploring the Role of an Implantable Doppler Probe in Kidney Transplantation: A Feasibility Randomized Controlled Trial with an Embedded Qualitative Study

OBJECTIVES

Vascular complications in kidney transplant surgery constitute one-third of early graft loss, which can be prevented by timely diagnosis of vascular compromise. A blood flow monitoring device may have a beneficial role in the early identification of graft hypoperfusion critical to reducing graft loss. This research protocol aims to evaluate the potential of an implantable Doppler probe as a blood flow monitoring device in kidney transplant recipients.

MATERIALS AND METHODS

The potential study will be a mixed methodology, 2-arm feasibility randomized controlled trial with an embedded qualitative study. For the trial, we will compare demographic characteristics and outcome measures of kidney transplant patients receiving implantable Doppler probe monitoring (intervention group, n = 30) with those having standard clinical care (control group). For the qualitative study, we will conduct semi-structured interviews with stakeholders (n = 12) recruited by purposive sampling to explore experiences of participants. All interviews will be audio recorded with verbatim transcription.

RESULTS

Our results will use the summarized quantitative data and descriptive statistics to determine differences between the groups. We will use CONSORT guidelines to determine the suitability of the research processes, availability of research resources, and potential challenges faced during the feasibility randomized controlled trial. We will use thematic analysis and NVivo software to analyze the acceptability of the intervention in clinical practice. We will compile the results according to the consolidated criteria for reporting qualitative research checklist.

CONCLUSIONS

The goal of this protocol is to determine the feasibility of an implantable Doppler probe monitoring device in kidney transplant recipients. The feasibility study will collect preliminary information, fill gaps in evidence, and test research processes for the pragmatic future randomized controlled trial. The template of this study is transferable to other transplant centers across the United Kingdom.

The Cost-Effectiveness of Kidney Replacement Therapy Modalities: A Systematic Review of Full Economic Evaluations

BACKGROUND

Kidney replacement therapy (KRT) is a lifesaving but costly treatment for patients with end-stage kidney disease (ESKD). The objective of this study was to review full economic evaluations comparing KRT modalities specified as hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KT) for patients with ESKD.

METHODS

We conducted a systematic review of the literature from PubMed, Embase, EconLit (EBSCO), Web of Science, Cochrane Library, National Health Service Economic Evaluation Database (NHS EED), Centre for Reviews and Dissemination (CRD) Database of Abstracts of Reviews of Effects (DARE), and CRD Health Technology Assessment Database from inception until 5 January 2020. Full economic evaluations were included if they compared three forms of KRT specified as PD, HD, and KT. The reporting quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

Ten studies were identified in the review. The majority of the studies were model-based evaluations and included a cost-utility analysis. Four studies were conducted from a public healthcare perspective, three from a societal perspective, and three from a third-party payer perspective. None of the studies adequately addressed all the applicable items of the CHEERS checklist. The most infrequently reported items were characterizing heterogeneity, target population, and characterizing uncertainty. There is a lack of studies that conduct from a societal perspective and take into account characterizing heterogeneity. All included studies indicate that KT is the most cost-effective KRT modality, with either a dominant position over HD and PD or an incremental cost-effectiveness ratio well below the accepted willingness-to-pay threshold. The majority of studies suggest that PD is less costly and offers comparable or better health outcomes than HD.

CONCLUSIONS

Our systematic review suggests that KT is the most cost-effective KRT modality, but there is no firm conclusion about the cost-effectiveness of HD and PD. Further economic evaluations can be conducted from a societal perspective and detail the evidence for subsets of patients with different characteristics.