Cost-effectiveness of losartan in diabetic nephropathy: a Greek perspective.

BACKGROUND: Diabetic nephropathy is the primary cause of end-stage renal disease (ESRD), which involves substantial economic burden. The primary objective of this study was to estimate the potential effect of losartan on the costs associated with ESRD in patients with diabetic nephropathy in a Greek setting. A secondary aim was to approximate the direct health care cost of renal replacement therapy (RRT) in Greece. METHODS: A cost-effectiveness analysis was performed to compare losartan with placebo in patients with type 2 diabetes and nephropathy. Clinical data were derived from the RENAAL study. All costs were calculated from the perspective of the Greek social insurance system, in 2003 euros. Future costs were discounted at 3%. The time horizon was 3.5 years. Extensive sensitivity analyses were performed. RESULTS: The reduction in the number of ESRD days over 3.5 years in patients treated with losartan reduced ESRD-related costs by 3,056.54 euros, resulting in net cost savings of 1,665.43 euros per patient. Net cost savings increase thereafter, increasing to 2,686.48 euros per patient over a period of 4.0 years. The results were robust under a wide range of plausible assumptions. The weighted mean daily cost of RRT was estimated at 90.97 euros per patient. The total economic burden of RRT for the year 2003 has been estimated at 304.773 million euros. CONCLUSIONS: This study demonstrated that treatment of patients with diabetic nephropathy in Greece with losartan is cost-effective, as it leads to important savings for the social insurance system by slowing the progression to ESRD.

Destructive spondyloarthropathy in a patient on continuous ambulatory peritoneal dialysis for 13 years.

Since 1984 there have been reports of a destructive spondyloarthropathy occurring in patients on long-term hemodialysis. The primary abnormality appears to be an accumulation of beta 2-microglobulin, which is not adequately removed by dialysis, and forms amyloid deposits in articular and periarticular tissues. We report a case of this disease in a patient treated only by peritoneal dialysis. While this form of treatment may delay the development of arthropathy, as compared to hemodialysis, it does not prevent it. An increasing incidence of this disorder may be expected, since increasing numbers of patients have been on long-term peritoneal dialysis.

Recent developments in peritoneal dialysis.

Significant developments over the past 10 years have established continuous ambulatory peritoneal dialysis as a successful kidney-replacement treatment. Peritonitis rates have fallen, and investigators are attempting to establish objective criteria for adequacy of dialysis. Malnutrition is a serious concern, but short-term experience with intraperitoneal amino acids promises success in the management of this complication. A significant improvement in the well-being of patients with end-stage renal disease was produced by recombinant human erythropoietin, and use of recombinant human growth hormone promises catch-up growth for children receiving long-term peritoneal dialysis treatment. As increasing numbers of patients are maintained on continuous ambulatory peritoneal dialysis over longer periods, we will begin to encounter beta 2-microglobulin-related amyloidosis possibly at the same rate in these patients as in those receiving long-term hemodialysis treatment.