Economic evaluations of dialysis treatment modalities. Health Policy. 2008;86:163-180. [PMID: 18243397 DOI: 10.1016/j.healthpol.2007.12.004]

Urgent unplanned peritoneal dialysis versus hemodialysis in end-stage renal disease: Costs and outcomes

OBJECTIVE

To evaluate the efficacy and safety of urgent, unplanned peritoneal dialysis (PD) compared to hemodialysis (HD) in patients with end-stage renal disease (ESRD).

METHODS

This prospective cohort quasi-experimental study enrolled 60 ESRD patients requiring urgent, unplanned dialysis. Participants were randomly assigned to automated peritoneal dialysis (APD) or daily dialysis (HD) at a tertiary hospital from May 2021 to June 2023. The primary outcome was patient survival. Secondary outcomes included infection rates, bacteremia, mechanical complications, catheter loss, cost, and hospitalization. All patients were followed for 3 months. Baseline characteristics were similar between groups.

RESULTS

Of the 60 patients who started urgent unplanned dialysis, 5 (8.3%) died during the treatment and follow-up period. There was no significant difference in the mortality rate between PD patients (6.7%) versus HD patients (10.0%). Overall infection rates were higher in the HD group (40.0%) compared to the PD group (6.7%) (p = 0.014). HD patients had a significantly higher incidence of bacteremia in the follow-up period compared to PD patients (20.0% versus 10.0%, p < 0.01). HD patients also had longer hospitalization stays (13.6 ± 4.1 days) compared to PD patients (6.2 ± 3.3 days, p 0.014). Additionally, the overall cost of dialysis was significantly higher for HD patients compared to PD patients (p < 0.01).

CONCLUSION

Urgent, unplanned PD was as effective as HD in treating ESRD patients. PD was associated with lower infection rates, shorter hospital stays, and reduced costs, making it a safe, viable, and cost-effective option for urgent dialysis.

Perceived barriers to peritoneal dialysis utilization amongst South Asian nephrologists

Peritoneal dialysis (PD) is a well-established modality for kidney replacement therapy (KRT) globally, offering benefits such as better preservation of residual kidney function, improved quality of life, and reduced resource requirements. Despite these advantages, the global utilization of PD remains suboptimal, particularly in South Asia (SA), where a significant gap in PD delivery exists. This study aims to uncover the perceived barriers hindering PD utilization among nephrologists in SA. This is a cross-sectional survey involving 732 nephrologists from SA region. . The majority of respondents (44.7%) reported initiating less than six PD cases annually, reflecting low PD utilization. Cost and financial reimbursement policies emerged as major barriers, with 44.3% considering PD more expensive than haemodialysis (HD). Accessibility, negative attitudes toward PD, and fear of complications were identified as critical factors influencing PD adoption. The study also highlighted variations in PD costs among SA countries, emphasizing the need for tailored health economic strategies. This analysis provides insights into the multifaceted challenges faced by SA nephrologists in promoting PD and underscores the importance of targeted interventions.

Service Utilization Patterns and Direct Medical Costs of Hospitalization in Patients With Renal Failure Before and After Initiating Home Peritoneal Dialysis

OBJECTIVES

This study aimed to determine the hospital service utilization patterns and direct healthcare hospital costs before and during peritoneal dialysis (PD) at home.

METHODS

A retrospective cohort study of patients with kidney failure (KF) was conducted at a Mexican Social Security Institute hospital for the year 2014. Cost categories included inpatient emergency room stays, inpatient services at internal medicine or surgery, and hospital PD. The study groups were (1) patients with KF before initiating home PD, (2) patients with less than 1 year of home PD (incident), and (3) patients with more than 1 year of home PD (prevalent). Costs were actualized to international dollars (Int$) 2023.

RESULTS

We found that 53% of patients with KF used home PD services, 42% had not received any type of PD, and 5% had hospital dialysis while waiting for home PD. The estimated costs adjusting for age and sex were Int$5339 (95% CI 4680-9746) for patients without home PD, Int$17 556 (95% CI 15 314-19 789) for incident patients, and Int$7872 (95% CI 5994-9749) for prevalent patients; with significantly different averages for the 3 groups (P < .001).

CONCLUSIONS

Although the use of services and cost is highest at the time of initiating PD, over time, using home PD leads to a significant reduction in use of hospital services, which translates into institutional cost savings. Our findings, especially considering the high rates of KF in Mexico, suggest a pressing need for interventions that can reduce healthcare costs at the beginning of renal replacement therapy.

A Comparison of US Medicare Expenditures for Hemodialysis and Peritoneal Dialysis

BACKGROUND

Observations that peritoneal dialysis (PD) may be an effective, lower-cost alternative to hemodialysis for the treatment of ESKD have led to policies encouraging PD and subsequent increases in its use in the United States.

METHODS

In a retrospective cohort analysis of Medicare beneficiaries who started dialysis between 2008 and 2015, we ascertained average annual expenditures (for up to 3 years after initiation of dialysis) for patients ≥67 years receiving in-center hemodialysis or PD. We also determined whether differences in Medicare expenditures across dialysis modalities persisted as more patients were placed on PD. We used propensity scores to match 8305 patients initiating PD with 8305 similar patients initiating hemodialysis.

RESULTS

Overall average expenditures were US$108,656 (2017) for hemodialysis and US$91,716 for PD (proportionate difference, 1.11; 95% confidence interval [CI], 1.09 to 1.13). This difference did not change over time (P for time interaction term=0.14). Hemodialysis had higher estimated intravenous (iv) dialysis drug costs (1.69; 95% CI, 1.64 to 1.73), rehabilitation expenditures (1.35; 95% CI, 1.26 to 1.45), and other nondialysis expenditures (1.34; 95% CI, 1.30 to 1.37). Over time, initial differences in total dialysis expenditures disappeared and differences in iv dialysis drug utilization narrowed as nondialysis expenditures diverged. Estimated iv drug costs declined by US$2900 per patient-year in hemodialysis between 2008 and 2014 versus US$900 per patient-year in PD.

CONCLUSIONS

From the perspective of the Medicare program, savings associated with PD in patients ≥67 years have remained unchanged, despite rapid growth in the use of this dialysis modality. Total dialysis expenditures for the two modalities converged over time, whereas nondialysis expenditures diverged.

Financial Incentives to Facilities and Clinicians Treating Patients With End-stage Kidney Disease and Use of Home Dialysis: A Randomized Clinical Trial

Importance

Home dialysis rates for end-stage kidney disease (ESKD) treatment are substantially lower in the US than in other high-income countries, yet there is limited knowledge on how to increase these rates.

Objective

To report results from the first year of a nationwide randomized clinical trial that provides financial incentives to ESKD facilities and managing clinicians to increase home dialysis rates.

Design, Setting, and Participants

Results were analyzed from the first year of the End-Stage Renal Disease Treatment Choice (ETC) model, a multiyear, mandatory-participation randomized clinical trial designed and implemented by the US Center for Medicare & Medicaid Innovation. Data were reported on Medicare patients with ESKD 66 years or older who initiated treatment with dialysis in 2021, with data collection through December 31, 2021; the study included all eligible ESKD facilities and managing clinicians. Eligible hospital referral regions (HRRs) were randomly assigned to the ETC (91 HRRs) or a control group (211 HRRs).

Interventions

The ESKD facilities and managing clinicians received financial incentives for home dialysis use.

Main Outcomes and Measures

The primary outcome was the percentage of patients with ESKD who received any home dialysis during the first 90 days of treatment. Secondary outcomes included other measures of home dialysis and patient volume and characteristics.

Results

Among the 302 HRRs eligible for randomization, 18 621 eligible patients initiated dialysis treatment during the study period (mean [SD] age, 74.8 [1.05] years; 7856 women [42.1%]; 10 765 men [57.9%]; 859 Asian [5.2%], 3280 [17.7%] Black, 730 [4.3%] Hispanic, 239 North American Native, and 12 394 managing clinicians. The mean (SD) share of patients with any home dialysis during the first 90 days was 20.6% (7.8%) in the control group and was 0.12 percentage points higher (95% CI, -1.42 to 1.65 percentage points; P = .88) in the ETC group, a statistically nonsignificant difference. None of the secondary outcomes differed significantly between groups.

Conclusions and Relevance

The trial results found that in the first year of the US Center for Medicare & Medicaid Innovation-designed ETC model, HRRs assigned to the model did not have statistically significantly different rates in home dialysis compared with control HRRs. This raises questions about the efficacy of the financial incentives provided, although further evaluation is needed, as the size of these incentives will increase in subsequent years.

Trial Registration

ClinicalTrials.gov Identifier: NCT05005572.

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient's needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

OUP accepted manuscript

Patients on chronic hemodialysis are counseled to reduce dietary sodium intake to limit their thirst and consequent interdialytic weight gain (IDWG), chronic volume overload and hypertension. Low-sodium dietary trials in hemodialysis are sparse and mostly indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake and IDWG. Additional nutritional restrictions and numerous barriers further complicate dietary adherence. A low-sodium diet may also reduce tissue sodium, which is positively associated with hypertension and left ventricular hypertrophy. A potential alternative or complementary approach to dietary counseling is home delivery of low-sodium meals. Low-sodium meal delivery has demonstrated benefits in patients with hypertension and congestive heart failure but has not been explored or implemented in patients undergoing hemodialysis. The objective of this review is to summarize current strategies to improve volume overload and provide a rationale for low-sodium meal delivery as a novel method to reduce volume-dependent hypertension and tissue sodium accumulation while improving quality of life and other clinical outcomes in patients undergoing hemodialysis.

Do remote dialysis services really cost more? An economic analysis of hospital and dialysis modality costs associated with dialysis services in urban, rural and remote settings

Background

Rates of end-stage kidney disease in Australia are highest in the Northern Territory (NT), with the burden of disease heaviest in remote areas. However, the high cost of delivering dialysis services in remote areas has resulted in centralisation, requiring many people to relocate for treatment. Patients argue that treatment closer to home improves health outcomes and reduces downstream healthcare use. Existing dialysis cost studies have not compared total health care costs associated with treatment in different locations.

Objective

To estimate and compare, from a payer perspective, the observed health service costs (all cause hospital admissions, emergency department presentations and maintenance dialysis) associated with different dialysis models in urban, rural and remote locations.

Methods

Using cost weights attributed to diagnostic codes in the NT Department of Health’s hospital admission data set (2008–2014), we calculated the mean (SD) total annual health service costs by dialysis model for 995 dialysis patients. Generalized linear modeling with bootstrapping tested the marginal cost differences between different explanatory variables to estimate ‘best casemix’/‘worst casemix’ cost scenarios.

Results

The mean annual patient hospital expenditure was highest for urban models at $97 928 (SD $21 261) and $43 440 (SD $5 048) and lowest for remote at $19 584 (SD $4 394). When combined with the observed maintenance dialysis costs, expenditure was the highest for urban models at $148 510 (SD $19 774). The incremental cost increase of dialysing in an urban area, compared with a rural area, for a relocated person from a remote area, was $5 648 more and increased further for those from remote and very remote areas to $10 785 and $15 118 respectively.

Conclusions

This study demonstrates that dialysis treatment in urban areas for relocated people has health and cost implications that maybe greater than the cost of remote service delivery. The study emphasises the importance of considering all health service costs and cost consequences of service delivery models.

Key points for decision makers

Relocation for dialysis treatment has serious health and economic consequences. Relocated people have low dialysis attendance and high hospital costs in urban areas. While remote dialysis service models are more expensive than urban models, the comparative cost differences are significantly reduced when all health service costs are included. The delivery of equitable and accessible dialysis service models requires a holistic approach that incorporates the needs of the patient; hence dialysis cost studies must consider the full range of cost impacts beyond the dialysis treatments alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06612-z.

Most people requiring ongoing treatment for end-stage kidney disease in the Northern Territory (NT) identify as Aboriginal with the majority residing in areas classified as remote or very remote. Unlike other jurisdictions in Australia, haemodialysis in a satellite unit is the most common form of treatment. However, there is a geographic mismatch between demand and service provision, with services centralised in urban areas. Patients and communities have long advocated for services at or closer to home, maintaining that the consequences of relocation and dislocation have far reaching health, psychosocial and economic ramifications. We analysed retrospective hospital data for 995 maintenance dialysis patients, stratified by the model of care they received in urban, rural and remote locations. Using cost weights attributed to diagnosis codes, we costed hospital admissions, emergency department presentations and maintenance dialysis attendances, to provide a mean total health service cost/patient/year for each model of care. We found that urban services were associated with low observed maintenance dialysis and high hospital costs, but the inverse was true for remote and very remote models. Remote models had high maintenance dialysis costs (due to expense of remote service delivery and good dialysis attendance) but low hospital usage and costs. When adjusted for other variables such as age, dialysis vintage and comorbidities, lower total hospital costs were associated with rural and remote service provision. In an environment of escalating demand and constrained budgets, this study underlines the need for policy decisions to consider the full cost consequences of different dialysis service models.

Cost of Hemodialysis Treatment and Associated Factors Among End-Stage Renal Disease Patients at the Tertiary Hospitals of Addis Ababa City and Amhara Region, Ethiopia

Purpose

Hemodialysis is a renal replacement therapy for end-stage renal disease (ESRD) patients who consume substantial healthcare resources, which increases the economic burden. Plenty of factors affects the cost of hemodialysis treatment, particularly in resource-limited settings. Moreover, the demand for hemodialysis may decrease as the cost increases, but there is limited evidence in Ethiopia. Thus, this study aimed to estimate the cost of hemodialysis treatment among ESRD patients in the tertiary hospitals of Addis Ababa City and Amhara region, Ethiopia.

Patients and Methods

An institutional-based cross-sectional study was conducted among 172 ESRD patients undergoing hemodialysis treatment. A structured questionnaire and patients’ medical chart were used to estimate the costs, and the human capital approach was applied to calculate the indirect costs. A generalized linear model (GLM) was fitted after the modified park test to identify the associated factors. In the final GLM, a p-value of <0.05 and a 95% CI were used to declare the significant variables.

Results

The mean annual cost of hemodialysis treatment was 121,089.27ETB ($4466.59) ± 33,244.99 ($1226.29). The direct and indirect costs covered 77.0% and 23.0% of the total costs, respectively. Age (ex(b): 1.01, p-value <0.001), highest wealth status (ex(b): 1.09, p-value: 0.008), eight (ex(b): 1.27, p-value <0.001) and 12 visits/month (ex(b): 1.34, p-value <0.001), anemia (ex(b): 1.13, p-value <0.001), and comorbidity (ex(b): 1.09, p-value: 0.039) were the factors associated with the costs of hemodialysis treatment.

Conclusion

The annual cost of hemodialysis treatment among ESRD patients was high compared to the national per capita health expenditure, and two-thirds covered by the direct medical costs. Old age, high wealth status, more visits, anemia, and comorbidity were factors associated with the costs of hemodialysis. Therefore, the healthcare system must make a great effort for cost reduction and reduce the patients with kidney disease before they reach end-stages.

Direct medical costs of end-stage kidney disease and renal replacement therapy: a cohort study in Guangzhou City, southern China

BACKGROUND

Renal replacement therapy was a lifesaving yet high-cost treatment for people with end-stage kidney disease (ESKD). This study aimed to estimate the direct medical costs per capita of ESKD by different treatment strategies: haemodialysis (HD); peritoneal dialysis (PD); kidney transplantation (KT) (in the first year); KT (in the second year), and by two urban health insurance schemes.

METHODS

This was a retrospective observational cohort study. Data were obtained from outpatient and inpatient claims database of two urban health insurance from Guangzhou City, Southern China. Adult patients with HD (n = 3765; mean age 58 years), PD (n = 1237; 51 years), KT (first year) (n = 117; 37 years) and KT (second year) (n = 41; 39 years) were identified between 2010 and 2012. The primary outcome was the annual per patient medical costs in 2013 Chinese Yuan (CNY) incurred in the outpatient and inpatient sectors. Secondary outcomes were annual outpatient visits and inpatient admissions, length of stay per admission. Generalized linear regression and bootstrapping statistical methods were used for analysis.

RESULTS

The estimated average annual medical costs for patients on HD were CNY 94,760.5 (US$15,066.0), 95% Confidence Interval (CI): CNY85,166.6-106,972.2, which was higher than those for patients on PD [CNY80,762.9 (US$12,840.5), 95% CI: CNY 76,249.8-85,498.9]. The estimated annual cost ratio of HD versus PD was 1.17 (95% CI: 1.12-1.25). Among the transplanted patients, the estimated average annual medical costs in the first year were CNY132,253.0 (US$21,026.9), 95%CI: CNY114,009.9-153,858.6, and in the second year were CNY93,155.3 (US$14,810.8), 95%CI: CNY61,120.6-101,989.1. The mean annual medical costs for dialysis patients under Urban Employee-based Basic Medical Insurance scheme were significantly higher than those for patients under Urban Resident-based Basic Medical Insurance scheme (P < 0.001).

CONCLUSIONS

The direct medical costs of ESKD patients were high and different by types of renal replacement therapy and insurance. The findings can be used to conduct cost-effectiveness research on different types of RRT for ESKD patients that provides economic evidence for health policy design in China.

Cost Controversies of a "Home Dialysis First" Policy

Purpose of review

Kidney Failure is highly prevalent and uses a disproportionate amount of health care funding. In Canada (excluding Quebec), 37 647 people were living with kidney failure in 2016. The single-payer Canadian health care system spends approximately 1.2% of their annual budget on kidney failure. In 2016, 58.4% of patients with kidney failure in Canada (excluding Quebec) were on dialysis as opposed to living with a functioning kidney transplant. Home dialysis modalities including peritoneal dialysis (PD) and home hemodialysis (HD) were used by 18.9% and 4.7% of these patients, respectively. In-center HD and home dialysis (PD and home HD) are often considered equally efficacious and have similar impacts on quality of life. Despite cost minimization analyses suggesting that home dialysis offers cost savings over in-center HD, there has been a slow uptake of home dialysis in developed nations over time, suggesting that controversies and barriers to implementation currently exist. The primary objective of this health policy briefing article is to introduce and address some of the major controversies surrounding the cost effectiveness in supporting advocacy for a "Home Dialysis First" policy with a primary focus on single-payer systems in a developed nation such as Canada.

Sources of information

Canadian Agency for Drugs and Technologies in Health (CADTH), Canadian and US epidemiologic databases, national/international conference presentations, primary literature review, and discussion with experts within the field of home dialysis.

Methods

We have conducted a focused primary literature review alongside individuals with expertise in the field of home dialysis to discuss the cost controversies surrounding the implementation of a "Home Dialysis First" policy.

Key findings

First, the primary literature is limited to mostly observational studies which are highly variable in study design and content. Local economic assessments, however, have provided convincing data for home dialysis cost savings in Canada. Second, the cost of delivering dialysis differs significantly throughout the world, explained by differing costs of labor and supplies in developing nations. Third, the indirect patient costs of water, energy, and home modifications are often barriers to implementation and may be overcome by introducing cost reimbursement programs. Fourth, home dialysis requires upfront training costs. We explore the impact of premature switches from home dialysis to in-center HD or a functioning kidney transplant on overall cost savings. Fifth, we discuss the effect of physician financial incentives and program funding on the uptake of home dialysis. Finally, we introduce the controversial topic of comparing the societal value of freedom of modality choice against the societal cost savings of a "Home Dialysis First" policy.

Limitations

Narrative reviews, due to their inherently reduced methodological quality in comparison with systematic reviews, may expose our collected literature to selection bias. We have attempted to compose a diverse collection of available literature alongside consensus expertise to provide a fair and concise review of home dialysis cost controversies.

Implications

Implementation of a "Home Dialysis First" policy would be a disruptive change to kidney failure care in Canada. To make informed policy decisions, we should recognize the cost savings associated with home dialysis in developed nations, the significance of patient-borne costs as a barrier to implementation, the impact of training costs and early modality switching in home dialysis, the lack of evidence regarding physician financial incentives, and the importance of program funding. Ultimately, we must consider the societal value of freedom of patient modality choice in comparison with the potential cost savings of a "Home Dialysis First" policy.

Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis

BACKGROUND

Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT).

METHODS

We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars.

RESULTS

There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies.

CONCLUSION

The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Patient assessment of chronic kidney disease self-care using the chronic kidney disease self-care scale in Taiwan

AIM

Self-care represents the 'action' element of self-management. This study aimed to use the chronic kidney disease self-care (CKDSC) scale to examine factors associated with self-care and aspects of self-care deficits among CKD patients in Taiwan.

METHODS

A cross-sectional investigation was conducted using the CKDSC scale with 449 CKD patients in Taiwan. The CKDSC is a 16-item questionnaire with five subscales, including medication adherence, diet control, exercise, smoking behaviours and blood pressure monitoring. Patient demographic and clinical factors taht may affect CKD self-care were analyzed in the multivariable regression models.

RESULTS

Overall CKDSC scores were significantly higher for women (P = 0.020), older patients (P < 0.001), higher education (P = 0.033), BMI <24 kg/m² (P = 0.005), later CKD stage or participants in the CKD care programme. Early-stage CKD patients had significantly lower for medication adherence, diet control, and blood pressure monitoring. Patients who participated in the CKD care programme had higher for medication adherence, diet control and regular exercise habits.

CONCLUSION

The CKDSC scale is a tool to assess patient self-care. However, given the CKDSC tool is in Chinese, future studies should validate it in CKD patients in other languages or countries before it can be considered for general use.

The Financial Cost Incurred by Families of Children on Long-Term Dialysis

BACKGROUND

Costs of dialysis reported in countries where dialysis is government-funded are often those incurred by the state, and only a few take into account the financial burden to the family of the index patient. This study investigated the financial cost implication to families of pediatric patients on maintenance dialysis and how aid provided by the government alleviates their financial burden.

METHODS

This descriptive cross-sectional study recruited 24 children on peritoneal dialysis (PD) and hemodialysis (HD), and a structured questionnaire was administered to the parents/caregivers of these patients to obtain information on their family size, total family income, cost of transportation, employment status of attending caregiver, and number of work days missed due to hospital visits.

RESULTS

Complete data were available for 19 patients (7 on PD and 12 on HD). The mean age was 14 ± 6 years, and there were 11 males and 8 females. The average monthly income of the families recruited was 2,946 ZAR (261 USD). This amount included the contribution of a monthly state-provided social grant of 1,300 ZAR (115 USD) in 16/19 subjects. The average monthly expenditure of the HD and PD groups made up 27.1% and 4.9% of their average income.

CONCLUSION

Transport cost for our patients on dialysis significantly impacts on the overall family income, especially for patients on HD, and, without government aid, the families of our patients would have far less money available for their daily needs.

PD First Policy: Thailand's Response to the Challenge of Meeting the Needs of Patients With End-Stage Renal Disease

Providing dialysis for end-stage kidney disease (ESKD) patients nationwide in a developing country such as Thailand is challenging. Even after roll-out of the Thai Universal Coverage Scheme in 2002, treatment for ESKD was not covered and patients struggled to afford dialysis. There was an urgent need to improve financial risk protection for patients with ESKD. Advocacy by nephrologists, health economists, and civil society seeking equity in access to dialysis, and responsiveness from policy makers, led to the methodical development of the Peritoneal Dialysis (PD) First policy and marked a turning point in ESKD care in Thailand. Despite the obvious economic concerns and the prevailing popularity of hemodialysis the policy has been strategically and successfully implemented since 2008. The Thai PD First policy has saved the lives of nearly 50,000 ESKD patients being dialyzed under the universal coverage scheme. Despite ongoing challenges the program continues to evolve. This article summarizes the key strategies underlying the policy development and implementation, the integration of home-based dialysis into the well-established Thai health care system, the use of the Chronic Care Model concept in PD care, and the impact of choosing PD as the first choice of dialysis therapy, which has slowed the growth of dialysis costs.

Economic evaluation of a pre-ESRD pay-for-performance programme in advanced chronic kidney disease patients

Background

The National Health Insurance Administration in Taiwan initiated a nationwide pre-end-stage renal disease (ESRD) pay-for-performance (P4P) programme at the end of 2006 to improve quality of care for chronic kidney disease (CKD) patients. This study aimed to examine this programme's effect on patients' clinical outcomes and its cost-effectiveness among advanced CKD patients.

Methods

We conducted a longitudinal observational matched cohort study using two nationwide population-based datasets. The major outcomes of interests were incidence of dialysis, all-cause mortality, direct medical costs, life years (LYs) and incremental cost-effectiveness ratio comparing matched P4P and non-P4P advanced CKD patients. Competing-risk analysis, general linear regression and bootstrapping statistical methods were used for the analysis.

Results

Subdistribution hazard ratio (95% confidence intervals) for advanced CKD patients enrolled in the P4P programme, compared with those who did not enrol, were 0.845 (0.779-0.916) for incidence of dialysis and 0.792 (0.673-0.932) for all-cause mortality. LYs for P4P and non-P4P patients who initiated dialysis were 2.83 and 2.74, respectively. The adjusted incremental CKD-related costs and other-cause-related costs were NT$114 704 (US$3823) and NT$32 420 (US$1080) for P4P and non-P4P patients who initiated dialysis, respectively, and NT$-3434 (US$114) and NT$45 836 (US$1572) for P4P and non-P4P patients who did not initiate dialysis, respectively, during the 3-year follow-up period.

Conclusions

P4P patients had lower risks of both incidence of dialysis initiation and death. In addition, our empirical findings suggest that the P4P pre-ESRD programme in Taiwan provided a long-term cost-effective use of resources and cost savings for advanced CKD patients.

Therapeutic efficacy of bone marrow derived mesenchymal stromal cells versus losartan on adriamycin-induced renal cortical injury in adult albino rats

BACKGROUND

Renal disease is a major health problem. Recent studies have reported the efficacy of stem cell therapy in nephropathy animal models.

AIM OF THE WORK

This study was designed to investigate the therapeutic effectiveness of bone marrow-derived mesenchymal stromal cells (MSCs) versus losartan in the treatment of renal alterations induced by adriamycin (ADR).

MATERIALS AND METHODS

Thirty-five adult male albino rats were divided into four groups. Group I was the control group. Group II (adriamycin-treated group),which included ten rats that were injected with a single dose of adriamycin (15 mg/kg) intraperitoneally, was subdivided into subgroup IIa and IIb and they were sacrificed 1 week and 5 weeks after adriamycin injection, respectively. Group III was the adriamycin + losartan-treated group and 1 week after adriamycin injection five rats received 10 mg/kg of losartan orally and daily for 4 weeks. Group IV was the adriamycin + MSC-treated group); five rats were injected with adriamycin as group II then supplied with MSCs at a dose of 1 × 10(6) cells suspended in 0.5 mL of phosphate-buffered saline (PBS) per rat in the tail vein 1 week after adriamycin injection. Rats of this group were sacrificed 4 weeks after the stem cell injection. Blood urea nitrogen and serum creatinine were measured. Samples from renal cortex were processed for light and electron microscope examination. As regards light microscope, sections were stained with hematoxylin and eosin (H-E), periodic acid-Schiff (PAS), masson trichrome, proliferating cell nuclear antigen (PCNA) and Caspase-3 immunohistochemical stains. Morphometrical and statistical analyses were also conducted.

RESULTS

Examination of adriamycin-treated group revealed deterioration of renal functions and various degrees of renal structural alterations as vacuolated cytoplasm, dark nuclei and detached epithelial lining. Administration of losartan partially improved ADR-induced kidney dysfunction, whereas MSCs denoted a more ameliorative role evidenced by structural and functional recovery.

CONCLUSION

MSCs have a relevant therapeutic potential against ADR-induced renal damage. MSCs may accomplish this role by decreasing caspase-3 expression and increasing proliferating cell nuclear antigen staining which influence the regeneration of the kidney.

Economic evaluation of policy options for dialysis in end-stage renal disease patients under the universal health coverage in Indonesia

Objectives

This study aims to assess the value for money and budget impact of offering hemodialysis (HD) as a first-line treatment, or the HD-first policy, and the peritoneal dialysis (PD) first policy compared to a supportive care option in patients with end-stage renal disease (ESRD) in Indonesia.

Methods

A Markov model-based economic evaluation was performed using local and international data to quantify the potential costs and health-related outcomes in terms of life years (LYs) and quality-adjusted life years (QALYs). Three policy options were compared, i.e., the PD-first policy, HD-first policy, and supportive care.

Results

The PD-first policy for ESRD patients resulted in 5.93 life years, equal to the HD-first policy, with a slightly higher QALY gained (4.40 vs 4.34). The total lifetime cost for a patient under the PD-first policy is around 700 million IDR, which is lower than the cost under the HD-first policy, i.e. 735 million IDR per patient. Compared to supportive care, the incremental cost-effectiveness ratio of the PD-first policy is 193 million IDR per QALY, while the HD-first policy resulted in 207 million IDR per QALY. Budget impact analysis indicated that the required budget for the PD-first policy is 43 trillion IDR for 53% coverage and 75 trillion IDR for 100% coverage in five years, which is less than the HD-first policy, i.e. 88 trillion IDR and 166 trillion IDR.

Conclusions

The PD-first policy was found to be more cost-effective compared to the HD-first policy. Budget impact analysis provided evidence on the enormous financial burden for the country if the current practice, where HD dominates PD, continues for the next five years.

Economic and quality of care evaluation of dialysis service models in remote Australia: protocol for a mixed methods study

BACKGROUND

Australia's Northern Territory (NT) has the country's highest incidence and prevalence of kidney disease. Indigenous people from remote areas suffer the heaviest disease burden. Concerns regarding cost and sustainability limit the provision of dialysis treatments in remote areas and most Indigenous people requiring dialysis relocate to urban areas. However, this dislocation of people from their family, community and support networks may prove more costly when the broader health, societal and economic consequences for the individual, family and whole of government are considered.

METHODS

The Dialysis Models of Care Study is a large cross organisation mixed methods study. It includes a retrospective (2000-2014) longitudinal data linkage study of two NT cohorts: Renal Cohort 1- comprising approximately 2000 adults who received dialysis and Renal Cohort 2- comprising approximately 400 children of those adults. Linkage of administrative data sets from the Australian and New Zealand Dialysis and Transplant Registry, NT Departments of Health, Housing and Education by a specialist third party (SA/NT Datalink) will enable extraction of activity, financial and outcome data. Interviews with patients, clinicians and service providers, using a snowball technique, will canvass relevant issues and assist in determining the full costs and impacts of the five most used dialysis Models of Care.

DISCUSSION

The study uses a mixed methods approach to investigate the quantitative and qualitative dimensions of the full costs and outcomes associated with the choice of particular dialysis models of care for any given patient. The study includes a large data linkage component that for the first time links health, housing and education data to fully analyse and evaluate the impact on patients, their families and the broader community, resulting from the relocation of people for treatment. The study will generate a large amount of activity, financial and qualitative data that will investigate health costs less directly related to dialysis treatment, costs to government such as housing and/or education and the health, social and economic outcomes experienced by patients. This approach fills an evidence gap critical to health service planners.

A comprehensive approach to assess the costs of renal replacement therapy for end-stage renal disease in France: the importance of age, diabetes status, and clinical events

OBJECTIVES

In the current pressured economic context, and to continue to treat the growing number of patients with high-quality standards, the first step is to have a better understanding of the costs related to end-stage renal disease (ESRD) treatment according to various renal replacement therapy, age, diabetes status, and clinical events.

METHODS

In order to estimate the direct costs of all adult ESRD patients, according to (RRT) modality, patient condition, and clinical events, data from the French national health insurance funds were used.

RESULTS

The mean monthly costs for the 47,862 stable prevalent patients (73 % of the population) varied substantially according to treatment modality (from 7300€ for in-center hemodialysis to 1100€ for a functioning renal graft) and to clinical event (8300€ for the first month of dialysis, 11,000€ for the last month before death, 22,800€ for the first month after renal transplantation). Mean monthly costs varied according to diabetic status and to age to a lesser extent.

CONCLUSIONS

These results demonstrate, for the first time in France and in Europe, the importance of a dynamic view of renal care and the bias likely when comparing treatments in cross-sectional studies.

A societal cost-of-illness study of hemodialysis in Lebanon

AIM

Renal failure is a growing public health problem, and is mainly treated by hemodialysis. This study aims to estimate the societal costs of hemodialysis in Lebanon.

METHODS

This was a quantitative, cross-sectional cost-of-illness study conducted alongside the Nutrition Education for Management of Osteodystrophy trial. Costs were assessed with a prevalence-based, bottom-up approach, for the period of June-December 2011. The data of 114 patients recruited from six hospital-based units were collected through a questionnaire measuring healthcare costs, costs to patients and family, and costs in other sectors. Recall data were used for the base-case analysis. Sensitivity analyses employing various sources of resources use and costs were performed. Costs were uprated to 2015US$. Multiple linear regression was conducted to explore the predictors of societal costs.

RESULTS

The mean 6-month societal costs were estimated at $9,258.39. The larger part was attributable to healthcare costs (91.7%), while costs to patient and family and costs in other sectors poorly contributed to the total costs (4.2% and 4.1%, respectively). In general, results were robust to sensitivity analyses. Using the maximum value for hospitalization resulted in the biggest difference (+15.5% of the base-case result). Female gender, being widowed/divorced, having hypertension comorbidity, and higher weekly time on dialysis were significantly associated with greater societal costs.

LIMITATIONS

Information regarding resource consumption and cost were not readily available. Rather, they were obtained from a variety of sources, with each having its own strengths and limitations.

CONCLUSION

Hemodialysis represents a high societal burden in Lebanon. Using extrapolation, its total annual cost for the Lebanese society is estimated at $61,105,374 and the mean total annual cost ($18,516.7) is 43.70% higher than the gross domestic product per capita forecast for 2015. Measures to reduce the economic burden of hemodialysis should be taken, by promoting chronic kidney disease's prevention and encouraging transplantation.

Healthcare costs of the progression of chronic kidney disease and different dialysis techniques estimated through administrative database analysis

BACKGROUND

Chronic kidney disease (CKD) progression is associated with significant comorbidities and costs. In Italy, limited evidence of healthcare resource consumption and costs is available. We therefore aimed to investigate the direct healthcare costs in charge to the Lombardy Regional Health Service (RHS) for the treatment of CKD patients in the first year after starting hemodialysis and in the 2 years prior to dialysis.

METHODS

Citizens resident in the Lombardy Region (Italy) who initiated dialysis in the year 2011 (Jan 1 to Dec 31) were selected and data were extracted from Lombardy Regional databases on their direct healthcare costs in the first year after starting dialysis and in the 2 years prior to it was analyzed. Drugs, hospitalizations, diagnostic procedures and outpatient costs covered by RHS were estimated. Patients treated for acute kidney injury, or who died or stopped dialysis during the observational period were excluded.

RESULTS

From the regional population (>9,700,000 inhabitants), 1067 patients (34.3 % females) initiating dialysis were identified, of whom 82 % underwent only hemodialysis (HD), 13 % only peritoneal dialysis (PD) and the remaining 5 % both treatments. Direct healthcare costs/patient were € 5239, € 12,303 and € 38,821 (€ 40,132 for HD vs. € 30,444 for PD patients) for the periods 24-12 months pre-dialysis, 12-0 months pre-dialysis, and in the first year of dialysis, respectively.

CONCLUSIONS

This study highlights a significant economic burden related to CKD and an increase in direct healthcare costs associated with the start of dialysis, pointing to the importance of prevention programs and early diagnosis.

Spatial Analysis of Case-Mix and Dialysis Modality Associations

♦

BACKGROUND

Health-care systems must attempt to provide appropriate, high-quality, and economically sustainable care that meets the needs and choices of patients with end-stage renal disease (ESRD). France offers 9 different modalities of dialysis, each characterized by dialysis technique, the extent of professional assistance, and the treatment site. The aim of this study was 1) to describe the various dialysis modalities in France and the patient characteristics associated with each of them, and 2) to analyze their regional patterns to identify possible unexpected associations between case-mixes and dialysis modalities. ♦

METHODS

The clinical characteristics of the 37,421 adult patients treated by dialysis were described according to their treatment modality. Agglomerative hierarchical cluster analysis was used to aggregate the regions into clusters according to their use of these modalities and the characteristics of their patients. ♦

RESULT

The gradient of patient characteristics was similar from home hemodialyis (HD) to in-center HD and from non-assisted automated peritoneal dialysis (APD) to assisted continuous ambulatory peritoneal dialysis (CAPD). Analyzing their spatial distribution, we found differences in the patient case-mix on dialysis across regions but also differences in the health-care provided for them. The classification of the regions into 6 different clusters allowed us to detect some unexpected associations between case-mixes and treatment modalities. ♦

CONCLUSIONS

The 9 modalities of treatment available make it theoretically possible to adapt treatment to patients' clinical characteristics and abilities. However, although we found an overall appropriate association of dialysis modalities to the case-mix, major inter-region heterogeneity and the low rate of peritoneal dialysis (PD) and home HD suggest that factors besides patients' clinical conditions impact the choice of dialysis modality. The French organization should now be evaluated in terms of patients' quality of life, satisfaction, survival, and global efficiency.

Haemodialysis for paediatric acute kidney injury in a low resource setting: experience from a tertiary hospital in South West Nigeria

Background

Acute kidney injury (AKI) is an important cause of preventable mortality among children. Management of AKI may require renal replacement therapy (RRT) but access to RRT for children in low resource settings is limited. Our study explored the role of haemodialysis in the management of children with AKI in a low resource setting in terms of aetiology and outcomes.

Methods

A review of patients managed in the Paediatric Nephrology Unit, University College Hospital Ibadan, South-West Nigeria, who underwent haemodialysis for AKI from January 2006 to December 2014.

Results

Sixty-eight patients (55.9% males), aged 3–16 (mean ± standard deviation, 9.0 ± 3.4) years were studied. The causes of AKI were sepsis (22.1%), malaria (17.6%) and glomerulonephritis (17.6%), intravascular haemolysis—cause unknown (16.2%), G6PDH deficiency (7.4%), malignancy (8.8%) and haemoglobinopathy (5.9%). The number of sessions of haemodialysis ranged from 1 to 10 (mode = 2 sessions) over a period of 1–55 days. Mortality was 27.9% (n = 19) and was related to the aetiology of AKI (P = 0.000): no deaths among patients with intravascular haemolysis or malaria, six deaths among patients with sepsis (40%), six (50%) among the patients with glomerulonephritis, while all the patients with malignancies died.

Conclusions

The outcome of haemodialysis for AKI in Nigeria is relatively good and is related to the underlying aetiology of AKI. In addition to peritoneal dialysis, intermittent haemodialysis may have a role in the management of paediatric AKI in low resource settings and should be supported.

The cost of dialysis in low and middle-income countries: a systematic review

Background

The cost of dialysis in low and middle-Income countries has not been systematically reviewed. The objective of this article is to systematically review peer-reviewed articles on the cost of dialysis across low and middle-income countries.

Methods

PubMed and Embase databases were searched for the year 1998 to March 2013, and additional studies were added from Google Scholar search. An article was included if two reviewers agreed that it had reported cost of dialysis from low and middle-Income countries.

Results

The annual cost per patient for hemodialysis (HD) ranged from Int$ 3,424 to Int$ 42,785, and peritoneal dialysis (PD) ranged from Int$ 7,974 to Int$ 47,971. Direct medical cost especially drugs and consumables for HD and dialysis solutions and tubing for PD were the main cost drivers.

Conclusion

The number of studies on the economics of dialysis in low and middle-income countries is limited. Few papers indicate that dialysis is an expensive form of treatment for the population of these countries and that the poorer countries have an over-proportional burden to finance dialysis services. Further research is needed to determine the cost of dialysis based on a standard methodology grounded on existing economic guidelines and to address the question whether dialysis should be an element of the essential package of health in resource-poor countries. Used data should be as complete as possible. In case of missing data, proxies can be used. In case of developing countries, expert interviews are often used for estimating missing information.

A Global Overview of the Impact of Peritoneal Dialysis First or Favored Policies: An Opinion

Given the ever-increasing burden of end-stage renal disease (ESRD) in a global milieu of limited financial and health resources, interested parties continue to search for ways to optimize dialysis access. Government and payer initiatives to increase access to renal replacement therapies (RRTs), particularly peritoneal dialysis (PD) and hemodialysis (HD), may have meaningful impacts from clinical and health-economic perspectives; and despite similar clinical and humanistic outcomes between the two dialysis modalities, PD may be the more convenient and resource-conscious option. This review assessed country-specific PD-First/Favored policies and their associated background, implementation, and outcomes. It was found that barriers to policy-implementation are broadly associated with government policy, economics, provider or healthcare professional education, modality-related factors, and patient-related factors. Notably, the success of a given country's PD-Favored policy was inversely associated with the extent of HD infrastructure. It is hoped that this review will provide a foundation across countries to share lessons learned during the development and implementation of PD-First/Favored policies.

A review of acute and chronic peritoneal dialysis in developing countries

Various modalities of renal replacement therapy (RRT) are available for the management of acute kidney injury (AKI) and end-stage renal disease (ESRD). While developed countries mainly use hemodialysis as a form of RRT, peritoneal dialysis (PD) has been increasingly utilized in developing countries. Chronic PD offers various benefits including lower cost, home-based therapy, single access, less requirement of highly trained personnel and major infrastructure, higher number of patients under a single nephrologist with probably improved quality of life and freedom of activities. PD has been found to be lifesaving in the management of AKI in patients in developing countries where facilities for other forms of RRT are not readily available. The International Society of Peritoneal Dialysis has published guidelines regarding the use of PD in AKI, which has helped in ensuring uniformity. PD has also been successfully used in certain special situations of AKI due to snake bite, malaria, febrile illness, following cardiac surgery and in poisoning. Hemodialysis is the most common form of RRT used in ESRD worldwide, but some countries have begun to adopt a 'PD first' policy to reduce healthcare costs of RRT and ensure that it reaches the underserved population.

Omeprazole for prevention of upper gastrointestinal bleeding in uremia patients with hemofiltration: Clinical efficacy and nursing

AIM: To assess the clinical efficacy of omeprazole to prevent upper gastrointestinal bleeding in uremia patients with hemofiltration and determine appropriate nursing measures.

METHODS: One hundred and twelve patients with uremia treated at our hospital were divided into either a control group or a treatment group, both of which received hemofiltration and targeted nursing. The treatment group was additionally given omeprazole treatment. Clinical efficacy was observed and compared for the two groups.

RESULTS: The gastric pH, incidence rate of upper gastrointestinal bleeding and mortality rate of the control group were 5.22 ± 1.43, 12.5% and 7.1%, respectively; the corresponding values in the treatment group were 6.54 ± 1.54, 1.8% and 0.0%. The gastric pH was significantly higher in the treatment group that in the control group (P < 0.05), while the incidence rate of upper gastrointestinal bleeding and mortality rate were significantly lower in the treatment group (P < 0.05). The rates of nausea and vomiting, headache, anemia and diarrhea did not differ significantly between the control group and treatment group (5.4% vs 3.6%, 3.6% vs 1.8%, 0.0% vs 0.0%, 3.6% vs 0.0%, P > 0.05).

CONCLUSION: Using omeprazole to prevent upper gastrointestinal bleeding in uremia patients with hemofiltration is effective.

Evaluating the benefits of home-based peritoneal dialysis

Peritoneal dialysis (PD) is an effective renal replacement strategy for patients suffering from end-stage renal disease. PD offers patient survival comparable to or better than in-center hemodialysis while preserving residual kidney function, empowering patient autonomy, and reducing financial burden to payors. The majority of patients suffering from kidney failure are eligible for PD. In patients with cardiorenal syndrome and uncontrolled fluid status, PD is of particular benefit, decreasing hospitalization rates and duration. This review discusses the benefits of chronic PD, performed by the patient or a caregiver at home. Recognition of the benefits of PD is a cornerstone in stimulating the use of this treatment strategy.

Economic evaluation of urgent-start peritoneal dialysis versus urgent-start hemodialysis in the United States

Patients presenting late in the course of kidney disease who require urgent initiation of dialysis have traditionally received temporary vascular catheters followed by hemodialysis. Recent changes in Medicare payment policy for dialysis in the USA incentivized the use of peritoneal dialysis (PD). Consequently, the use of more expeditious PD for late-presenting patients (urgent-start PD) has received new attention. Urgent-start PD has been shown to be safe and effective, and offers a mechanism for increasing PD utilization. However, there has been no assessment of the dialysis-related costs over the first 90 days of care. The objective of this study was to characterize the costs associated with urgent-start PD, urgent-start hemodialysis (HD), or a dual approach (urgent-start HD followed by urgent-start PD) over the first 90 days of treatment from a provider perspective. A survey of practitioners from 5 clinics known to use urgent-start PD was conducted to provide inputs for a cost model representing typical patients. Model inputs were obtained from the survey, literature review, and available cost data. Sensitivity analyses were also conducted. The estimated per patient cost over the first 90 days for urgent-start PD was $16,398. Dialysis access represented 15% of total costs, dialysis services 48%, and initial hospitalization 37%. For urgent-start HD, total per patient costs were $19,352, and dialysis access accounted for 27%, dialysis services 42%, and initial hospitalization 31%. The estimated cost for dual patients was $19,400. Urgent-start PD may offer a cost saving approach for the initiation of dialysis in eligible patients requiring an urgent-start to dialysis.

Management of End Stage Renal Disease-Bangladesh Perspective

End stage renal disease (ESRD) is an important cause of morbidity and mortality throughout the world. The treatment of renal replacement therapy (RRT) for patients with ESRD is expensive. There is a direct relationship between per capita income and treatment of ESRD. Eighty five per cent of the world’s population lives in low income or middle-income countries, where the mortality is highest in patients with chronic kidney disease.

The future perspective is not satisfactory for Bangladesh where treatment of ESRD is out of reach for majority of people. Effort should made for prevention and treatment of CKD at an initial stage of disease.

Chronic Kidney Disease: Evolution of Healthcare Costs and Resource Consumption from Predialysis to Dialysis in Piedmont Region, Italy

This study aims at assessing the evolution in healthcare costs for chronic kidney disease (CKD) patients through the analysis of administrative databases of Piedmont region, Italy. This is a retrospective, observational study, for which patients undergoing at least one dialysis for CKD in the period of June 1, 2010–May 31, 2011 were selected. Two subpopulations were evaluated: patients incident-to-dialysis observed for the 12 months preceding dialysis entrance (PreD) and “established” dialysis patients (at least 120 dialyses/year) observed for 12 months (EstD). Overall, 1,059 PreD and 2,018 EstD patients were selected. The average yearly cost per PreD patient accounted for 11,123€ ± 15,095€ (75% hospitalizations, 17% drugs, and 8% diagnostic/therapeutic procedures). The average yearly cost per EstD patient accounted for 53,764€ ± 14,685€ (59% dialysis, 21% diagnostic/therapeutic procedures, 13% hospitalizations, and 6.7% drugs). Among EstD population, hemodialysis patients cost 56,049€ ± 13,473€ per year, whereas peritoneal dialysis patients cost 34,978€ ± 10,847€ per year. The significant difference in expenditure between predialysis and dialysis suggests that prevention, early diagnosis, and the consequent possible delay of dialysis entrance could lead to important savings for healthcare services, as well as a better global health status for patients.

Drugs to foster kidney regeneration in experimental animals and humans

BACKGROUND

The incidence of kidney diseases is increasing worldwide and they are emerging as a major public health problem. Once mostly considered inexorable, renal disease progression can now be halted and lesions can even regress with drugs such as angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II type I receptor blockers, indicating the possibility of kidney repair.

SUMMARY

The discovery of renal progenitor cells lining the Bowman capsule of adult rat and human kidneys has shed light on the mechanism of repair by ACEi. Parietal progenitors are a reservoir of cells that contribute to podocyte turnover in physiological conditions. In the early phases of renal disease these progenitors migrate chaotically and subsequently proliferate, accumulating in Bowman's space. The abnormal behavior of parietal progenitors is sustained by the activation of CXCR4 receptors in response to an increased production of the chemokine SDF-1 by podocytes activated by the inflammatory environment. Ang II, via the AT1 receptor, also contributes to progenitor cell proliferation. The CXCR4/SDF-1 and Ang II/AT1 receptor pathogenic pathways both pave the way for lesion formation and subsequent sclerosis. ACEi normalize the CXCR4 and AT1 receptor expression on progenitors, limiting their proliferation, concomitant with the regression of hyperplastic lesions in animals, and in a patient with crescentic glomerulopathy.

KEY MESSAGE

Understanding the molecular and cellular determinants of regeneration triggered by renoprotective drugs will reveal novel pathways that might be challenged or targeted by pharmacological therapy.

Clinical effects of hemodialysis versus peritoneal dialysis in end-stage renal disease patients with advanced cirrhosis

AIM: To compare the clinical effects of hemodialysis and peritoneal dialysis in end-stage renal disease (ESRD) patients with advanced cirrhosis.

METHODS: ESRD patients with cirrhosis who were treated at our hospital were randomly divided into either a control group or an observation group. The control group was treated by hemodialysis 2 to 3 times a week, while the observation group was treated by peritoneal dialysis 3 to 4 times daily.

RESULTS: After treatment, blood pressure, plasma total protein, albumin levels were significantly lower, and BUN and SCr were significantly higher in the observation group than in the control group (P < 0.05 for all), but serum calcium, ammonia and hemoglobin levels showed no significant difference between the two groups (P > 0.05 for all). The incidence of adverse reactions (51.6% vs 74.2%) was significantly lower and the survival rate (91.9% vs 74.2% ) was significantly higher in the observation group than in the control group (P < 0.05 for both). The observation group had significantly lower average monthly cost than the control group (P < 0.05).

CONCLUSION: Hemodialysis and peritoneal dialysis are both effective in ESRD patients with advanced cirrhosis, with the latter being associated with a higher survival rate, fewer side effects, and less cost.

Peritoneal dialysis and the process of modality selection

The process of modality selection and how it works is a critical determinant of peritoneal dialysis (PD) utilization. This very complex process has not been well analyzed. Here, we break it down into 6 steps and point out how problems at each step can significantly reduce the proportion of endstage renal disease patients initiating PD. It is important that any program wishing it to grow its use of PD understand the steps and the points at which problems may be arising. Examples are presented.

The role of economies of scale in the cost of dialysis across the world: a macroeconomic perspective

BACKGROUND

The treatment of chronic kidney disease through dialysis is a considerable expense in most health systems. The two chief methods of providing dialysis, haemodialysis (HD) and peritoneal dialysis (PD) have significant differences in cost composition and factors of production. The aim of this article is to identify and quantify the macroeconomic variables that influence the relative cost of such modalities across different countries.

METHODS

From previously published literature, we extracted the estimates of HD/PD cost ratios in a total of 46 countries. We conducted a multivariate regression analysis using the estimated HD/PD cost ratio in each country, with several country level indicators as explanatory variables. We found a strong statistical effect of the following variables on the HD/PD cost ratio: country's level of development, economies of scale and percentage of private health-care expenditure.

RESULTS

The statistical effects on HD/PD ratio by local manufacturing and relaxed import regulation of PD equipment were calculated and were found to be very significant.

CONCLUSIONS

it is possible for a country to still reap the benefits of economies of scale in provision of PD, even in the absence of a large enough market to make local production of PD equipment feasible in that country.

A patient perspective on the barriers to home dialysis

INTRODUCTION

People with End Stage Renal Disease rarely choose home dialysis therapies even though they can offer a range of Quality-of-Life (QOL) benefits such as improved convenience, mental health well-being, employment, reduced mortality and cost effectiveness. Attempts to increase usage of such self-caring modalities, have met with limited success, in part due to a lack of understanding of patient decision making and patient perceived barriers to such therapies.

OBJECTIVE

To explore the patient perspective on the main barriers to a range of self-care or home dialysis therapies, including Continuous Ambulatory Peritoneal Dialysis, Home Haemodialysis and Extended Home Haemodialysis.

MATERIALS AND METHODS

A longitudinal patient narrative approach is adopted.

RESULTS

There are significant barriers to all aspects of informed decision making around home therapies, but many are based on perception. Creating decision aids and education programmes to tackle these perceived barriers, actively encouraging home therapy take up, focusing on QOL in clinical decision making, offering peer support and expanded in-centre self-care treatment options may increase awareness and uptake of self-care therapies.

Comparison of cost-utility between automated peritoneal dialysis and continuous ambulatory peritoneal dialysis

BACKGROUND AND AIMS

The use of automated peritoneal dialysis (APD) is increasing compared to continuous ambulatory peritoneal dialysis (CAPD). Surprisingly, little data about health benefits and cost of APD exist, and virtually no information comparing the cost-utility between CAPD and APD is available. We undertook this study to evaluate and compare the health-related quality of life (HRQOL) and cost-utility indexes in patients on CAPD vs.

APD METHODS

This was a prospective cohort of patients initiating dialysis (2008-2009). Two questionnaires were self-administered: European Research Questionnaire Quality of Life (EQ-5D) and Kidney Disease Quality of Life (short form, KDQOL-SF, Rand, Santa Monica, CA). Direct medical costs (DMC) were determined from the health provider perspective including the following medical resource utilization: outpatient clinic/emergency care, dialysis procedures, medications, laboratory tests, hospitalization, and surgery. Cost-utility indexes were calculated dividing total mean cost by indicators of the HRQOL.

RESULTS

One hundred twenty-three patients were evaluated: 77 on CAPD and 46 on APD. Results of the EQ-5D and KDQOL-SF questionnaires were significantly better in APD compared to the CAPD group. Main costs in both APD and CAPD were attributed to hospitalization and dialysis procedures followed by medication and surgery. Outpatient clinic visits and laboratory tests were significantly more costly in CAPD than in APD, whereas dialysis procedures were more expensive in the latter. Cost-utility indexes were significantly better in APD compared to CAPD.

CONCLUSIONS

A significant cost-utility advantage of APD vs. CAPD was observed. The annual DMC per-patient were not different between groups but the HRQOL was better in the APD compared to the CAPD group.

Management and outcome in hepatorenal syndrome: need for renal replacement therapy in non-transplanted patients

PURPOSE

Hepatorenal syndrome (HRS) type I is a devastating complication of decompensated cirrhosis. Liver transplantation (LT) offers an excellent survival, and renal replacement therapy (RRT) may be useful until transplantation is available. The survival benefit of RRT in the absence of LT is thought to be short and its benefit in these patients is unknown. To investigate this, we studied the outcome of different therapies (pharmacological, RRT, and LT) in patients with type 1 HRS.

METHODS

Medical records (2005-2009) of all cirrhotic patients admitted to our facility with abnormal renal function were reviewed. Patients with preexisting renal disease, diagnosis other than type I HRS, or those without long-term follow-up were excluded.

RESULTS

Of 380 patients reviewed, 30 were studied. Nineteen (63.3 %) patients underwent liver transplantation. No difference in baseline liver or renal parameters was noted between those who were or were not transplanted. A decreased mortality was noted (5.3 vs. 64.6 %; p = 0.0005) compared to patients who were not transplanted during the study follow-up median period of 7.8 [CI 1.9-34] months. Among non-transplanted patients, no differences in median survival (8.8 vs. 6.5 months; p = 0.62) or in other parameters studied were found in those patients who received RRT compared to those who did not. Similarly, no survival difference was found comparing those who did or did not receive pharmacological therapy without transplant.

CONCLUSION

In type I HRS, LT offers better survival. Among patients who do not receive LT, RRT does not provide an improved survival benefit.

The cost-utility of haemodiafiltration versus haemodialysis in the Convective Transport Study

BACKGROUND

Despite the growing interest in haemodiafiltration (HDF), there is no information on the costs and cost-utility of this dialysis modality yet. It was therefore our objective to study the cost-utility of HDF versus haemodialysis (HD).

METHODS

A cost-utility analysis was performed using a Markov model. It included data from the Convective Transport Study (CONTRAST), a randomized controlled trial that compared online HDF with low-flux HD. Costs were estimated using a societal perspective. Probabilistic sensitivity analyses were performed to study uncertainty.

RESULTS

Total annual costs for HDF and HD were €88 622±19,272 and €86,086±15,945, respectively (in 2009 euros). When modelled over a 5-year period, the incremental cost per quality-adjusted life year (QALY) of HDF versus HD was €287,679. Sensitivity analyses revealed that this amount will not fall below €140,000, even under the most favourable assumptions like a high-convection volume (>20.3 L).

CONCLUSIONS

Based on accepted societal willingness-to-pay thresholds, HDF cannot be considered a cost-effective treatment for patients with end-stage renal disease at present. Apparently, minor additional costs of HDF are not counterbalanced by a relevant QALY gain.

The coming fiscal crisis: nephrology in the line of fire

Nephrologists in the United States face a very uncertain economic future. The astronomical federal debt and unfunded liability burden of Medicare combined with the aging population will place unprecedented strain on the health care sector. To address these fundamental problems, it is conceivable that the federal government will ultimately institute rationing and other budget-cutting measures to rein in costs of ESRD care, which is generously funded relative to other chronic illnesses. Therefore, nephrologists should expect implementation of cost-cutting measures, such age-based rationing, mandated delayed dialysis and home therapies, compensated organ donation, and a shift in research priorities from the dialysis to the predialysis patient population. Nephrologists also need to recognize that these changes, which are geared toward the population level, may make it more difficult to advocate effectively for the needs of individual patients.

Peritoneal dialysis--current status and future challenges

Peritoneal dialysis is now a well established, mature treatment modality for advanced chronic kidney disease. The medium term (at least 5 year) survival of patients on peritoneal dialysis is currently equivalent to that of those on haemodialysis, and is particularly good in patients who are new to renal replacement therapy and have less comorbidity. Nevertheless the modality needs to keep pace with the constantly evolving challenges associated with the provision and delivery of health care. These challenges, which are gradually converging at a global level, include ageing of the population, multimorbidity of patients, containment of cost, increasing self care and environmental issues. In this context, peritoneal dialysis faces particular challenges that include multiple barriers to the therapy and unsatisfactory and poorly defined technique survival as well as limitations relating to intrinsic aspects of the therapy, such as peritoneal membrane longevity and hypoalbuminaemia. To move the therapy forward and favourably influence health-care policy, the peritoneal dialysis community needs to integrate their research effort more effectively by undertaking clinically meaningful studies-with a strong focus on technique survival--that are supported by multidisciplinary expertise in patient-centred outcomes, study design and analysis.

Lifetime costs for peritoneal dialysis and hemodialysis in patients in Taiwan

BACKGROUND

This study compared the lifetime costs for peritoneal dialysis (PD) and hemodialysis (HD) patients in Taiwan.

METHODS

Using the National Health Insurance (NHI) database of all end-stage renal disease patients on maintenance dialysis registered from July 1997 to December 2005, we matched eligible PD patients with eligible HD patients on age, sex, and diabetes status. The matched patients were followed until 31 December 2006. Patients were excluded if they were less than 18 years of age, had been diagnosed with cancer before dialysis, or had been dialyzed at centers or clinics other than hospitals. Outcomes-including life expectancy, total lifetime costs, and costs per life-year paid by the NHI-were estimated and compared.

RESULTS

The 3136 pairs of matched PD and HD patients had a mean age of 53.2 ± 15.4 years. The total lifetime cost for PD patients (US$139 360 ± US$8 336) was significantly lower than that for HD patients (US$185 235 ± US$9 623, p < 0.001). Except for patients with diabetes (who had a short life expectancy), the total lifetime cost was significantly lower for PD patients than for HD patients regardless of sex and age (p < 0.01).

CONCLUSION

In Taiwan, the total lifetime costs paid by the NHI were lower for PD than for HD patients.