Cost-Effectiveness of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease and Acute Coronary Syndromes in the US Medicare Program.

Background Coronary revascularization provides important long-term clinical benefits to patients with high-risk presentations of coronary artery disease, including those with chronic kidney disease. The cost-effectiveness of coronary interventions in this setting is not known. Methods and Results We developed a Markov cohort simulation model to assess the cost-effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease who were hospitalized with acute myocardial infarction or unstable angina. Model inputs were primarily drawn from a sample of 14 300 patients identified using the Medicare 20% sample. Survival, quality-adjusted life-years, costs, and cost-effectiveness were projected over a 20-year time horizon. Multivariable models indicated higher 30-day mortality and end-stage renal disease with both PCI and CABG, and higher stroke with CABG, relative to medical therapy. However, the model projected long-term gains of 0.72 quality-adjusted life-years (0.97 life-years) for PCI compared with medical therapy, and 0.93 quality-adjusted life-years (1.32 life-years) for CABG compared with PCI. Incorporation of long-term costs resulted in incremental cost-effectiveness ratios of $65 326 per quality-adjusted life-year gained for PCI versus medical therapy, and $101 565 for CABG versus PCI. Results were robust to changes in input parameters but strongly influenced by the background costs of the population, and the time horizon. Conclusions For patients with chronic kidney disease and high-risk coronary artery disease presentations, PCI and CABG were both associated with markedly increased costs as well as gains in quality-adjusted life expectancy, with incremental cost-effectiveness ratios indicating intermediate value in health economic terms.

Regenerative treatments for kidney diseases: The closest and fastest strategies to solving related medical and economic problems.

Recent advances in developmental biology and stem cell biology have led to the increased availability of extrarenal stem cells, including mesenchymal/stromal stem cells (MSCs), renal stem or progenitor cells isolated from embryonic and adult kidneys, and kidney lineage cells or tissues generated from human pluripotent stem cells (hPSCs), such as human embryonic stem cells and human-induced pluripotent stem cells. Regenerative medicine strategies for kidney diseases are largely categorized into the transplantation of reconstructed kidney organs and cell therapies. Reconstruction is being attempted by hPSC-derived kidney lineage cells with various strategies, such as self-organization, interspecies blastocyst complementation, utilization of a xenogeneic organ niche, decellularization and repopulation, and 3D bioprinting. However, cell therapies using extrarenal stem cells, such as MSCs, and renal stem or progenitor cells derived from embryonic and adult kidneys or differentiated from hPSCs have been investigated in animal models of both acute kidney injury and chronic kidney disease. Indeed, multiple clinical trials using MSCs, bone marrow stem cells, and kidney-derived cells have already been carried out. This review summarizes the current status and future perspective of kidney regenerative medicine strategies and discusses the closest and fastest strategies to solving the medical and economic problems associated with kidney diseases.

Features of patient-education websites for patients with chronic kidney disease: an analysis of recommended websites.

BACKGROUND: Chronic kidney disease (CKD) requires lifelong self-management. With the rise in access to the Internet, many CKD patients and their caregivers increasingly use the internet for information on CKD self-management. A recent environmental scan by Smekal et al. identified 11 CKD-related websites that covered the greatest number of content areas. This paper aims to evaluate these 11 selected websites in order to identify those that most effectively address content areas relevant to patients with CKD. METHODS: Each website was assessed for information to 6 content areas: diet, physical activity, financial information, emotional support, general CKD information, and medication adherence. A three-tiered scoring metric was used in which a 0 was given if a content area was completely unaddressed, a (+) was given for a category that was generally addressed, and a (++) was given for a category that was addressed with actionable guidance. RESULTS: While CKD information and diet were very comprehensively covered with scores of 11 (++) and 8 (++), respectively; physical activity, emotional support and medication adherence received the fewest (++) scores (3 for physical activity and five for both emotional support and medication adherence). For each content area, recommendations are made for websites that are particularly useful. Common themes for these highlighted websites include specific instructions, multiple modalities of information, downloadable and printable resources, and contact references for personal inquiries. CONCLUSION: The recommended websites can help CKD patients and caregivers utilize the most applicable information for their specific self-management needs. Website improvements related to physical activity, emotional support, and financial information for persons with CKD are warranted.

Economic benefit of prescribing an adjusted renal dose of dipeptidyl peptidase IV inhibitors in type 2 diabetes patients with chronic kidney disease.

Highlights Based on nationwide insurance data in Korea, the use of dipeptidyl peptidase IV inhibitors (DPP-IVi) not requiring renal dose adjustment (NRDA DPP-IVi) is widespread in the type 2 diabetes chronic kidney disease (T2D CKD) population. Instead of prescribing NRDA DPP-IVi, the use of DPP-IVi requiring renal dose adjustment with appropriate renal dose adjustments in T2D CKD patients can achieve a considerable annual cost saving of up to 7.8%.

Socioeconomic disadvantage and the risk of advanced chronic kidney disease: results from a cohort study with 1.4 million participants.

BACKGROUND: Several studies have investigated the effect of socioeconomic deprivation on cardiovascular disease (CVD) and diabetes; less is known about its effect on chronic kidney disease (CKD). We aimed to measure the association between deprivation, CKD Stages 4-5 and end-stage renal disease (ESRD) in a general population sample. METHODS: This observational study examined 1 405 016 participants from the English Clinical Practice Research Datalink (2000-14), linked to hospital discharge data and death certification. Deprivation was assessed according to the participant's postcode. Cox models were used to estimate hazard ratios (HRs) for CKD Stages 4-5 and ESRD, adjusting for age and sex, and additionally for smoking status, body mass index, diabetes, systolic blood pressure, prior CVD and estimated glomerular filtration rate (eGFR) at baseline. RESULTS: During 7.5 years of median follow-up, 11 490 individuals developed CKD Stages 4-5 and 1068 initiated ESRD. After adjustment for age and sex, the HRs and confidence interval (CI) comparing those in the 20% most deprived of the population to the 20% least deprived were 1.76 (95% CI 1.68-1.84) and 1.82 (95% CI 1.56-2.12) for CKD Stages 4-5 and ESRD, respectively. Further adjustment for known risk factors and eGFR substantially attenuated these HRs. Adding our results to all known cohort studies produced a pooled relative risk of 1.61 (95% CI 1.42-1.83) for ESRD, for comparisons between highest to lowest categories of deprivation. CONCLUSION: Socioeconomic deprivation is independently associated with an increased hazard of CKD Stages 4-5 and ESRD, but in large part may be mediated by known risk factors.

La enfermedad renal crónica de causa no tradicional (ERCnT): una visión desde la protección social y la economía preventiva / Chronic kidney disease of unknown cause (CKDu): A vision from social protection and preventive economy

La presente es una ponencia presentada durante la realización del Seminario de Enfermedad Renal Crónica no Tradicional, celebrado en ciudad de Guatemala en junio de 2019. El mismo busca el enfoque de tal enfermedad desde una perspectiva económica de costos, y previsión en la seguridad social, buscando el ahorro de prestaciones pecuniarias en materia de discapacidad para los trabajadores de arduas tareas agrícolas estacionales, principalmente en la costa sur. El enfoque se efectúa desde el ámbito de la Economía Preventiva, y las experiencias en costos sociales del autor, concluyendo que tal enfermedad se encuentra en ascenso y amerita de políticas de salud curativa y preventiva, para impedir la discapacidad de trabajadores agrícolas muy jóvenes, quienes gracias a una resolución especial de la Junta Directiva del Instituto Guatemalteco de Seguridad Social (Igss), son cubiertos.

This paper is based on a lecture given at the Seminar on Chronis Kidney Disease of Unknown Cause, celebrated in Guatemala City, in June 2019. The focus is placed on the perspective of the preventive economy framework and the discipline of social and economic costs, this time associated with heat stress of labor in agricultural activities, and the measures taken by the Social Security Institute of Guatemala, aiming to protect the seasonal workers. The critic nature of the analysis allows to present some recommendations for the future of the social protection policies in Guatemala.

La determinación económica, social y laboral de la enfermedad renal crónica de causas no tradicionales (ERCnT) en la costa sur de Guatemala / The economic, social and labor determination of chronic kidney disease of non-traditional causes (CKDnT) on the southern coast of Guatemala

La flexibilidad laboral es característica de la producción estacional agroindustrial, cuyo principal problema es aprovechar con intensidad los períodos en los que se incrementa la producción. Pero, ¿cómo la demandante competitividad laboral influye en las estrategias de los trabajadores para incrementar su productividad? A partir de esta pregunta, se identificaron los aspectos económicos, sociales y laborales que inciden en la salud, así como las respuestas para disminuir el dolor físico y aumentar las exigencias de competitividad, flexibilización y desregularización del mercado de trabajo. La exposición ambiental y ocupacional en las condiciones de trabajo, el estrés térmico asociado a la deshidratación en la actividad física intensa, el limitado acceso a los servicios de salud, la mala alimentación y la pobre calidad de vida, también pueden producir otras enfermedades como diabetes e hipertensión, así como infecciones y lesiones renales. En ese contexto, en los últimos 20 años, se empezaron a reportar casos de enfermedad renal. La metodología cualitativa aplicada a este estudio, permitió llevar a cabo un proceso investigativo descriptivo e interpretativo sobre la forma en que los sujetos interactúan. Para ello se utilizaron las trayectorias laborales como técnicas en la recolección de datos. Los resultados arrojaron información relevante sobre las estrategias que los trabajadores utilizan para incrementar su rendimiento laboral, entre ellas la automedicación de vitaminas y analgésicos para tratar los espasmos musculares, que estimulan el sistema nervioso central, así como de bebidas saborizadas y energizantes con posibles repercusiones en la excreción renal.

Labor flexibility is characteristic of seasonal agroindustrial production whose main problem is to take advantage of the periods in which production increases. But, how does this demanding labor competitiveness influence workers' strategies to increase their productivity? From this question, the economic, social and labor aspects that affect health were identified, as well as the answers to reduce physical pain and increase the demands for competitiveness, flexibility and deregulation of the labor market. Environmental and occupational exposure in working conditions, thermal stress associated with dehydration in intense physical activity, limited access to health services, poor diet and quality of life, can also cause other diseases such as diabetes and hypertension, as well as infections and kidney lesions. In that context, in the last 20 years, cases of kidney disease began to be reported. The qualitative methodology applied to this study, allowed to carry out a descriptive and interpretive investigation process on the way in which the subjects interact, for this, the work trajectories were used as techniques in data collection. The results yielded relevant information on the strategies that workers use to increase their work performance, including self-medication of "vitamins" and analgesics to treat muscle spasms, drugs that stimulate the central nervous system, as well as flavored and energizing drinks with possible repercussions on renal excretion.

Economic Evaluation of Ferric Carboxymaltose for the Management of Hemodialysis Patients with Iron Deficiency Anemia in Italy.

INTRODUCTION: Patients with chronic kidney disease on hemodialysis (HD) are at high risk of developing both iron deficiency and iron deficiency anemia (IDA). The administration of intravenous iron therefore represents the standard of care for the management of anemia in this patient setting. METHODS: A retrospective cohort of 38 HD patients in Italy was analyzed to assess the clinical and economic implications of switching from intravenous ferric gluconate (FG) to ferric carboxymaltose (FCM) on achievement of adequate hemoglobin (Hb) values and iron balance. The total observational period for each patient was 12 months, 6 months before and 6 months after switching to iron FCM. The pharmacoeconomic analysis considered the hospital perspective and the consumption of iron, blood transfusions and erythropoiesis-stimulating agents (ESAs), including healthcare personnel time. RESULTS: Switching from FG to FCM in dialysis adult patients with IDA allows a cost reduction per patient/month in the range €14-46, considering the use of biosimilar ESA or originator ESA, respectively. The percentage of patients with Hb target values increased from 63% to 82%, considering the entire observation period. In addition, other clinical parameters (ferritin, transferrin saturation, erythropoietin resistance index) improved after switching from FG to FCM. CONCLUSION: FCM in HD patients was shown to provide a favorable efficacy profile over FG, with a lower cost per patient, mainly driven by a consistent reduction of ESA consumption. FUNDING: Vifor Pharma Italia Srl.

Adverse Safety Event Characteristics and Predictive Factors in Hospital Encounters for Patients with Chronic Kidney Disease.

BACKGROUND: Adverse safety events (ASE) during hospitalization may contribute to renal decline or poor outcomes. Understanding factors contributing to ASE in chronic kidney disease (CKD) is limited. The objective is to compare differences and determine predictors of renal pertinent ASE in discharges for CKD. METHOD: A cross-sectional analysis of the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality 2012 data. The study included adults age ≥18 years with discharge diagnosis for CKD stages 1-4, excluding cancer of the kidney and renal pelvis, renal transplant, end-stage renal disease. Predictors included study sample characteristics, including patient demographics, comorbidity, and hospitalization-related variables. Outcomes assessed included distribution of ASE (angioedema, confusion, muscle weakness or cramps, lower extremity edema (LEE), falls, hypoglycemia, nausea-vomiting-diarrhea (NVD), and skin rash), mean total charge per hospital event, and length-of-stay. The analytical approach used descriptive statistics (means and proportions) and bivariate analysis to compare differences (ASE versus none). Predictors of ASE were explored using multivariate logistic regression. RESULTS: 10.3% of inpatient discharges for CKD showed an ASE. Mean charges (USD 48,072 vs. 46,996), days length-of-stay (6.8 vs. 5.7), number of diagnosis on record (6.8 vs. 5.7), geographical region (Midwest, and West), and type of hospital (rural) were significantly associated with ASE. Most common ASEs were confusion (18%), LEE (21.3%), and NVD (50.7%). Odds of ASE increased for age, female gender, rural hospitals, geographical region, and diagnosis for anemia, coagulopathies, depression, fluid and electrolyte disorders, neurological disorders, psychoses, and weight loss. CONCLUSIONS: We identified key factors that increase the risk of ASE in patients with CKD. Opportunities exist to reduce ASE in CKD.

Cost-utility analysis of the National Health Screening Program for chronic kidney disease in Korea.

AIM: Although a National Health Screening Program (NHSP) for chronic kidney disease (CKD) has been implemented in Korea since 2002, its cost-effectiveness has never been determined. This study aimed to estimate the cost-utility of NHSP for CKD in Korea. METHODS: A Markov decision analytic model was constructed to compare CKD screening strategies of the NHSP with no screening. We developed a model that simulated disease progression in a cohort aged 20-120 years or death from the societal perspective. RESULTS: Biannual screening starting at age 40 for CKD by proteinuria (dipstick) and estimated glomerular filtration ratio had an ICUR of $66 874/QALY relative to no screening. The targeted screening strategy had an ICUR of $37 812/QALY and $40 787/QALY for persons with diabetes and hypertension, respectively. ICURs improved with lower cost strategies. The most influential parameter that might make screening more cost-effective was the effectiveness of treatment on CKD to decrease disease progression and mortality. CONCLUSIONS: The Korean NHSP for CKD is more cost-effective for patients with diabetes or hypertension than the general population, consistent with prior studies. Although it is too early to conclude the cost-effectiveness of the Korean NHSP for CKD, this study provides evidence that is useful in evaluating the cost-effectiveness of CKD interventions.

Healthcare resource use and costs associated with chronic kidney disease in US private insurance patients with multiple myeloma.

OBJECTIVES: Within a median 1.2 years after patients have an initial diagnosis with multiple myeloma, up to 61% were diagnosed with renal impairment and 50% were diagnosed with chronic kidney disease. This study estimated economic burden associated with chronic kidney disease in multiple myeloma patients in the US. METHODS: In this retrospective cohort study, patients ≥18 years old with ≥1 inpatient or ≥ 2 outpatient multiple myeloma diagnoses between 1 January 2008 and 31 March 2015 were identified from MarketScan® Commercial and Medicare Supplemental Databases. Chronic kidney disease patients had ≥1 diagnosis of chronic kidney disease Stages 1-5 (first chronic kidney disease diagnosis date = index date) on or after the first multiple myeloma diagnosis, and were propensity score matched 1:1 to multiple myeloma patients without chronic kidney disease, end-stage renal disease, dialysis, or other type of chronically impaired renal function. All patients had ≥six-month continuous enrollment prior to index date and were followed for ≥one month from index date until the earliest of inpatient death, end of continuous enrollment, or end of the study period (30 September 2015). The per-patient per-year healthcare resource utilization and costs were measured during follow-up. Costs were total reimbursed amount in 2016 US dollars. RESULTS: A total of 2541 multiple myeloma patients with chronic kidney disease stages 1-5 and 2541 matched controls met the study criteria and were respectively 69.3 and 69.6 years, 54.5% and 55.3% men, and had 572.2 and 533.4 mean days of follow up. Compared to controls, chronic kidney disease patients had significantly (all P < 0.001) higher proportions (57.1% vs. 32.1%) and frequency (1.2 vs. 0.5) of inpatient admissions, frequency of emergency room visits (5.1 vs. 3.3), and total costs ($106,634 vs. $71,880). Sensitivity analyses found that patients with chronic kidney disease, end-stage renal disease, or dialysis had $78,455 ( P < 0.001) higher costs (per-patient per-year) than matched controls. CONCLUSIONS: The economic burden associated with chronic kidney disease in patients with multiple myeloma was estimated to be between $34,754 and $78,455 per-patient per-year. Given its substantial clinical and economic impact, preservation of renal function is important in multiple myeloma patient care.

Global costs attributed to chronic kidney disease: a systematic review

SUMMARY The aim of this study is to discuss the global costs attributed to chronic kidney disease (CKD) and its impact on healthcare systems of developing countries, such as Brazil. This is a systematic review based on data from PubMed/Medline, using the key words "costs" and "chronic kidney disease", in January 2017. The search was also done in other databases, such as Scielo and Google Scholar, aiming to identify regional studies related to this subject, published in journal not indexed in PubMed. Only papers published from 2012 on were included. Studies on CKD costs and treatment modalities were prioritized. The search resulted in 392 articles, from which 291 were excluded because they were related to other aspects of CKD. From the 101 remaining articles, we have excluded the reviews, comments and study protocols. A total of 37 articles were included, all focusing on global costs related to CKD. Despite methods and analysis were diverse, the results of these studies were unanimous in alerting for the impact (financial and social) of CKD on health systems (public and private) and also on family and society. To massively invest in prevention and measures to slow CKD progression into its end-stages and, then, avoid the requirement for dialysis and transplant, can represent a huge, and not yet calculated, economy for patients and health systems all over the world.

RESUMO O objetivo deste estudo é discutir os custos financeiros mundiais atribuídos à doença renal crónica (DRC) e suas repercussões sobre os sistemas de saúde em países em desenvolvimento, como o Brasil. Trata-se de uma revisão sistemática realizada na base de dados do PubMed/Medline, utilizando os termos em inglês "costs" e "chronic kidney disease", em janeiro de 2017. A busca foi ampliada a outros bancos, como o Scielo e o Google Acadêmico, com o objetivo de identificar estudos locais relacionados ao assunto, publicados em revistas não indexadas no PubMed. Foram incluídos apenas artigos publicados a partir de 2012. Priorizaram-se estudos que abordavam os custos da DRC e das modalidades de tratamento. A busca resultou em 392 artigos, dos quais foram excluídos 291 por fugirem da temática principal desta revisão. Dos 101 restantes, foram excluídos revisões, comentários e protocolos. Foram incluídos 37 artigos cujo foco eram os custos globais relacionados à DRC. Apesar de os métodos e análises serem diversos, os resultados dos estudos são unânimes em alertar sobre o forte impacto, financeiro e social, da DRC que atinge os sistemas de saúde, públicos e privados, portadores da doença, familiares e a sociedade. Investir maciçamente em prevenção e nas medidas para retardar a progressão da DRC para os estágios finais e, consequentemente, evitar a necessidade de diálise e transplante, podem representar uma enorme, e ainda não calculada, economia para pacientes e sistemas de saúde do mundo todo.

Burden of Anemia in Chronic Kidney Disease Patients in Japan: A Literature Review.

Anemia is a common complication for patients with chronic kidney disease (CKD) and is associated with cardiovascular comorbidities and reduced quality of life. The incidence of anemia increases as kidney function declines and affects approximately 32% of Japanese patients with stage 3-5 CKD. This review examined the current literature on anemia in CKD patients in Japan to provide an overview of the burden of anemia in CKD. Medline, Embase, and Igaku Chuo Zasshi databases were searched to identify relevant manuscripts and abstracts published from 2004 onward. The population included CKD patients with anemia, and the outcomes of interest were epidemiology, economic, humanistic, and treatment patterns. Observational studies, database analysis, and economic evaluation studies were included in the analysis. A total of 1151 references were identified, and 50 were eligible for final review. Economic burden was reported in most studies (n = 37) followed by treatment patterns (n = 26), and epidemiological (n = 25) and humanistic (n = 1) burdens. Prevalence of anemia varied largely (0-95%) based on the different definitions of anemia, and increased with CKD severity. Higher mortality was associated with erythropoiesis-stimulating agent (ESA) resistance and lower hemoglobin levels among patients treated with ESA. Drug dosage was the most reported economic burden (n = 33), followed by medical, and non-medical outcomes. Costs associated with anemia were considerable and depended on dialysis status and ESA treatment. Only one study reported data on quality of life, suggesting that further investigation on the humanistic burden of anemia in CKD is needed.

O custo do atendimento aos pacientes com doença renal crônica (DRC), em fase não dialítica de um hospital universitário / El coste del tratamiento a pacientes com enfermedad renal crónica (ERC), em fase no diálisis em um hospital académico / The caring costs for patients bearing chronic kidney disease (CKD), in a non-dialytic phase of a university hospital

Objetivo: Identificar o custo do atendimento aos pacientes com doença renal crônica (DRC), em fase não dialítica de um Hospital Universitário do Rio de Janeiro. O tratamento conservador é uma modalidade terapêutica que tem objetivo acompanhar o paciente em todos os estágios da doença. Métodos: Trata-se de um estudo de coorte retrospectivo com abordagem quantitativa e análise de custos realizada em um hospital universitário do estado do Rio de Janeiro. Resultados: Diante do estudo foram delimitados dados como idade, sexo, religião, escolaridade, raça, renda, tipo de acesso, modo de entrada em terapia dialítica, exames, consultas e suas especialidades e medicamentos. Discussão: foi discutido ponto a ponto de cada dado observado a fim de destacarmos os custos do tratamento conservador e o aspecto benéfico que está intimamente ligado. Conclusão: Evidencia-se, então, a necessidade de incentivar pesquisas para a temática quando aos aspectos epidemiológicos, financeiros e clínicos

Objetivo: El estudio tiene como objetivos: identificar el costo de la atención para los pacientes con enfermedad renal crónica (ERC) en la fase no-diálisis de un hospital universitario de Río de Janeiro. El tratamiento conservador es una modalidad terapéutica que tiene el objetivo de acompañar a los pacientes en todas las etapas de la enfermedad. Métodos: Se realizó un estudio de cohorte retrospectivo, con un enfoque de costos y análisis cuantitativo realizado en un hospital universitario en el estado de Río de Janeiro. Resultados: Antes del estudio se definieron los datos como la edad, el sexo, la religión, la educación, raza, ingresos, tipo de acceso, el modo de entrada en diálisis, exámenes, consultas y sus especialidades y medicamentos. Discusión: punto discutido por punto a cada uno de los datos observados con el fin de destacar los costos de tratamiento conservador y el aspecto beneficioso que está estrechamente vinculado. Conclusión: Se ve, pues, la necesidad de fomentar la investigación en el tema cuando la epidemiológica, clínica y financiera

Objective: The study's goal has been to identify the cost of care for patients bearing Chronic Kidney Disease (CKD) in a non-dialytic phase of a university hospital in Rio de Janeiro State. Conservative treatment is a therapeutic modality that aims to accompany the patient at all disease stages. Methods: This is a retrospective cohort study with a quantitative approach and cost analysis performed at a university hospital in Rio de Janeiro State. Results: In the study, data such as age, sex, religion, education, race, income, access type, mode of entry into dialytic therapy, exams, consultations and their specialties and medications were delimited. Discussion: It has been discussed under scrutiny each point from observed data in order to highlight the costs of conservative treatment, and also the beneficial aspect that is closely linked to it. Conclusion: There is a need for stimulating research regarding the topic, particularly, when it comes to epidemiological, financial and clinical aspects

Budget Impact Analysis of Oral Fisiogen Ferro Forte® versus Intravenous Iron for the Management of Iron Deficiency in Chronic Kidney Disease in Spain.

BACKGROUND: Iron deficiency is a frequent complication of chronic kidney disease (CKD) that is associated with a decrease in the quality of life of patients and an increase in the risk of other clinical complications. Iron therapy represents one of the fundamentals of patients with CKD. Sucrosomial® oral iron allows Fisiogen Ferro Forte® to be used in all patients who are intolerant to treatment by the oral route of administration, or who present with malabsorption of conventional oral iron preparations. OBJECTIVE: The main objective of this study was to assess the economic impact of the oral iron Fisiogen Ferro Forte® for the management of iron deficiency in CKD patients in Spain. METHODS: A 4-year budget impact model was developed for the period 2017-2020 for CKD patients with iron deficiency who were candidates for intravenous iron due to a lack of response to oral iron, from the perspective of the Spanish healthcare system. Three subgroups of CKD patients were included in the analysis: predialysis, peritoneal dialysis, and post-transplant. The intravenous iron formulations Ferinject®, Venofer®, and Feriv® were considered appropriate comparators to be used in the model. National data on the prevalence of CKD for the three subgroups of patients were obtained from the literature, and input data on drug utilization and outpatient hospitalizations associated with iron administration were obtained by consulting nephrologists. Nephrology experts were also asked about resources used during medical visits and monitoring tests. Based on the unit costs for each iron therapy and the resources used, the total treatment cost per patient associated with each product was obtained to estimate the global budget impact of increasing the use of Fisiogen Ferro Forte®. RESULTS: The average annual budget savings due to an increase in Fisiogen Ferro Forte® and a decrease in intravenous iron have been estimated at €398,685, €180,937, and €195,842 over 4 years for the predialysis, peritoneal dialysis, and post-transplant groups, respectively. CONCLUSIONS: The increase in the use of Fisiogen Ferro Forte® leads to overall budget savings of €775,464 for the Spanish National Health Service over 4 years.

Expenses of the Brazilian Public Healthcare System with chronic kidney disease / Gastos do Sistema Único de Saúde brasileiro com doença renal crônica

ABSTRACT Introduction: The prevalence of chronic kidney disease (CKD) is increasing worldwide, with costs that can be impeditive. Objective: To establish the expenses of the Brazilian Public Healthcare System (SUS), with hospitalizations due to CKD and related diseases; evaluating expenses with renal replacement therapy (RRT). Methods: We have assessed the values paid by the SUS in the triennium 2013-2015, for estimating annual expenses with CKD treatment and hospitalization, associated diseases, and exams. Results: There was an increase in hospitalization by all causes in Brazil during this triennium. CKD and associated diseases corresponded to 1.82% and 5.79% of hospitalizations due to all causes in Brazil, and 2.87% and 10.10% of all expenses, respectively. Kidney grafts from deceased donors corresponded to 76% of hospitalizations and 80% of expenses with transplantation. There was a decrease in transplantation from living donors. There was an increase in the number of exams of 11.94% and of 10.95% in the expenses. There was a decrease in the number of procedures and expenses in intermittent peritoneal dialysis (IPD) and related procedures; but other procedures increased. Hemodialysis (3 weekly sessions) corresponded to 95.96% of procedures and 96.07% of expenses with dialysis in general. Conclusion: Renal diseases and some of the main related diseases corresponded to 12.97% of the expenses in the triennium 2013-2015, and RRT to more than 5% of the SUS expenses with medium and high complexity healthcare. Such high expenses determine great concerns on the future maintenance of treatment for stage-5 CKD in Brazil and countries in similar or worse conditions of development.

RESUMO Introdução: A prevalência de doença renal crônica (DRC) está aumentando em todo o mundo, com custos que podem ser impeditivos. Objetivo: Estabelecer os gastos do Sistema Único de Saúde (SUS) com internação hospitalar por DRC e doenças relacionadas; avaliar os gastos com terapia renal substitutiva (TRS). Métodos: Avaliamos os valores pagos pelo SUS no triênio 2013-2015, para estimar as despesas anuais com tratamento da DRC e internação por DRC, doenças associadas e exames. Resultados: Houve aumento da hospitalização por todas as causas no Brasil neste triênio. A DRC e as doenças associadas corresponderam a 1,82% e 5,79% das internações hospitalares por todas as causas no Brasil, e 2,87% e 10,10% de todas as despesas, respectivamente. Os enxertos renais com doadores falecidos corresponderam a 76% das internações e 80% das despesas com o transplante. Houve uma diminuição em transplantes de doadores vivos. Houve um aumento no número de exames de 11,94% e em despesas de 10,95%. Houve uma diminuição no número de procedimentos e despesas em diálise peritoneal intermitente (IPD) e procedimentos relacionados; mas outros procedimentos aumentaram. A hemodiálise (3 sessões semanais) correspondeu a 95,96% dos procedimentos e 96,07% dos gastos com diálise em geral. Conclusão: As doenças renais e algumas das principais doenças relacionadas corresponderam a 12,97% das despesas no triênio 2013-2015 e a TRS a mais de 5% das despesas do SUS com atenção à saúde de média e alta complexidade. Tais gastos elevados determinam grandes preocupações quanto à manutenção futura do tratamento da DRC estágio 5 no Brasil e em países em condições de desenvolvimento semelhantes ou piores.

Reclassification of Chronic Kidney Disease Stage, Eligibility for Cystatin-C and Its Associated Costs in a UK Primary Care Cohort.

BACKGROUND AND AIMS: Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) estimations of glomerular filtration rate (eGFR), compared to modification of diet in renal disease (MDRD), have superior performance in predicting renal, cardiovascular and mortality events. Cystatin-C further improves prediction. Our primary aim was to assess the change in prevalence and classification of CKD in converting from MDRD to CKD-EPI in an unselected primary care CKD population. Our secondary aims were to determine the eligibility for cystatin-C testing based on National Institute for Health and Care Excellence guidance and the associated costs. METHODS: eGFR data from an unselected UK primary care CKD cohort was studied to assess reclassification of CKD stages from MDRD to CKD-EPI, suitability for cystatin-C testing and its associated cost. RESULTS: A total number of 24,660 individuals had ≥2 MDRD eGFR results <60 mL/min/1.73 m2 >3 months apart (7.0% of adult population). The mean age was 75.2 (SD 11.4 years) with 15,265 (61.9%) females. Mean eGFR was 2.88 mL/min/1.73 m2 lower with CKD-EPI eGFR versus MDRD eGFR (49.7 vs. 46.8, t test p < 0.0001, 95% CI 2.85-2.91). 12.0% of individuals were re-categorised to a more or less advanced CKD stage, and 1.3% to a less advanced stage. The percentage of the population categorised as 3a-A1 CKD-EPI and therefore potentially suitable for cystatin-C was 2.8%. The estimated initial cost is €67.5 (£57.2) million with annual costs of €2.7 (£2.3) million for the United Kingdom. CONCLUSIONS: The mean eGFR was lower with the CKD-EPI formula and individuals were more likely to be reclassified to more advanced CKD. This may be related to the higher mean age of this unselected population compared to previous studies. Refinements of eGFR formulae, CKD definitions and cystatin-C eligibility in unselected populations are required.

A Real-world Cost-effectiveness Analysis of Sevelamer Versus Calcium Acetate in Korean Dialysis Patients.

PURPOSE: Sevelamer, a noncalcium phosphate binder, has been shown to attenuate the progression of vascular calcification and improve survival in patients with chronic kidney disease undergoing dialysis compared with calcium-based binders. Using real-world data from a cohort study and the Health Insurance Review and Assessment Service database, we conducted a cost-effectiveness analysis comparing sevelamer with calcium acetate in dialysis patients from the perspective of the National Health Insurance Service in South Korea. METHODS: Data (demographic, diagnostic, laboratory, and survival) from 4674 patients undergoing dialysis enrolled in a multicenter prospective cohort study conducted in South Korea between September 2008 and December 2012 were linked to phosphate binder use, hospitalization, and cost data available from the Health Insurance Review and Assessment Service database. After propensity score matching, a dataset comprising comparable patients treated with either sevelamer (n = 501) or calcium acetate (n = 501) was used in the cost-effectiveness analysis. A Markov model was used to estimate costs, life years, quality-adjusted life years (QALYs), and cost-effectiveness over each patient's lifetime. Forty-month treatment-specific overall survival (OS) data available from the dataset were extrapolated to lifetime survival with the use of regression analysis. FINDINGS: Patients had a mean age of 56.3 years and were treated with dialysis for a mean duration of 67.6 months. Compared with calcium acetate, sevelamer was associated with an incremental cost of South Korean Won (₩) 12,246,911 ($10,819) and a gain of 1.758 life years and 1.108 QALYs per patient. This outcome yielded incremental cost-effectiveness ratios of ₩6,966,350 ($6154) and ₩11,057,699 ($9768) per life year and QALY gained, respectively. Conclusions regarding sevelamer's cost-effectiveness were insensitive to alternative assumptions in time horizon, discount rate, hospitalization rate, costs, and health utility estimates, and they remained consistent in 100% of the model iterations, considering a willingness-to-pay threshold of ₩31,894,720 ($28,176) per QALY gained. IMPLICATIONS: This analysis of real-world data found that sevelamer's higher cost relative to calcium acetate was adequately offset by improved survival among patients undergoing dialysis in South Korea. As such, sevelamer offers good value for money, representing a cost-effective alternative to calcium-based binders.

Costo por estadio de la atención integral del paciente diabético tipo 2 con enfermedad renal crónica / Cost per stage of comprehensive care of type 2 diabetic patients with chronic kidney disease / Custo por estágio de cuidados integrais de pacientes diabéticos de tipo 2 com doença renal crônica

Resumen Objetivo: Identificar el costo de la enfermedad renal crónica por estadio en pacientes con diabetes. Métodos: Estudio de costos en diabéticos tipo 2, se integraron cinco grupos definidos a partir del estadio de la enfermedad renal crónica. Se incluyeron aquellos con más de cinco años de evolución de la diabetes tipo 2, el tamaño de la muestra se calculó para cada estadio y la selección fue aleatoria simple. El diagnóstico por estadio se calculó mediante la ecuación de Cockcroft-Gault. El costo promedio se integró a partir del perfil de uso y el costo unitario, se realizó estimación de la proyección del costo, también se realizó estimación del costo para un paciente con 25 años de vida con enfermedad renal crónica. Resultados: En el estadio 1 el costo anual es $587.39, y en el estadio 5, $10,748.51. Otorgar la atención durante 25 años en una población de 100 pacientes diabéticos ajustados por letalidad, permanencia en el estadio e inflación cuesta $7,067,674 y el costo promedio de un individuo en este mismo escenario es $70,672. Conclusión: Se puede decir que el costo por estadio de la enfermedad renal crónica en el paciente diabético es alto con notable diferencia entre los distintos estadios.

Abstract Objective: To identify the cost of chronic kidney disease by stage in patients with diabetes. Methods: Cost study in type 2 diabetics, in five groups defined from the stage of chronic kidney disease. Those with more than five years of evolution of type 2 diabetes were included; the sample size was calculated for each stage and the selection was simple random. The diagnosis by stage was calculated using the Cockcroft-Gault equation. The average cost was integrated from the profile of use and the unit cost, estimation of the projection of the cost was made, an estimate of the cost was also made for a patient with 25 years old with chronic kidney disease. Results: In stage 1, the annual cost is $ 587.39, and in stage 5, $ 10,748.51. Caring for 25 years in a population of 100 diabetic patients adjusted for lethality, keeping the stadium and inflation costs $ 7,067,674, and the average cost of an individual in this same scenario is $ 70,672. Conclusion: It can be said that the cost per stage of chronic kidney disease in the diabetic patient is high, with marked difference between the different stages.

Resumo Objetivo: Identificar o custo da doença renal crônica por estágio em pacientes com diabetes Métodos: estudo de custo em diabéticos de tipo 2, em cinco grupos definidos a partir do estágio de doença renal crônica. Aqueles com mais de cinco anos de evolução do diabetes tipo 2 foram incluídos; o tamanho da amostra foi calculado para cada estágio e a seleção foi aleatória simples. O diagnóstico por fase foi calculado utilizando a equação de Cockcroft-Gault. O custo médio foi integrado a partir do perfil de uso e do custo unitário; foi feita uma estimativa da projeção do custo; e uma estimativa do custo também foi feita para um paciente com 25 anos com doença renal crônica. Resultados: Na fase 1, o custo anual é de US $ 587,39, e na etapa 5, $ 10,748.51. O cuidado por 25 anos em uma população de 100 pacientes diabéticos ajustados pela letalidade, mantendo o estádio e a inflação, custa US $ 7.067.674, e o custo médio de um indivíduo neste mesmo cenário é de US $ 70.672. Conclusão: pode-se dizer que o custo por estágio da doença renal crônica no paciente diabético é alto, com diferença acentuada entre os diferentes estágios.

Global impact of nephropathies.

The global burden of chronic kidney disease (CKD) has increased substantially in recent years, partly attributed to the global epidemic of diabetes mellitus. In many countries including China, glomerulonephritis was the most common cause of end stage renal disease (ESRD). The mortality rate of dialysis patients can be as high as patients with colon, breast and prostate cancers. CKD has important socio-economic impact on the healthcare system and society. Increasing awareness and early detection of CKD cannot be overemphasized. In places where healthcare resources are limited, peritoneal dialysis first policy has allowed local governments and health authorities to maximize healthcare resources to provide renal replacement therapy for more ESRD patients. In conclusion, management of CKD remains a global health challenge and continued medical research is most important.