Early versus standard renal replacement therapy after left ventricular assist device implantation.

OBJECTIVES: Renal function may improve after left ventricular assist device (LVAD) implant, however, some patients develop postoperative acute kidney injury (AKI). Randomized trials showed benefit for early renal replacement therapy (RRT) in critically ill patients with AKI, but this practice has not been studied in LVAD patients. METHODS: We performed a single-center, retrospective cohort study of all adults (>18 years) who underwent LVAD placement from 1/2010 to 12/2018. We collected preoperative, hemodynamic, echocardiographic, intraoperative, and postoperative data. AKI was defined according to Kidney Disease: Improving Global Outcomes definition. Early (E) RRT was considered treatment at AKI stage II or below. Standard (S) RRT was considered treatment at AKI stage III. Outcomes and Kaplan-Meier analysis were compared between groups. RESULTS: A total of 184 patients were included (mean age 56.10 years, 81% males, 30.4% African-American race). A total of 71 (38.6%) developed AKI and 17 (9.24%) needed RRT (11 E vs 6 S). A total of 11 remained hemodialysis-dependent at discharge (5 [45.5%] in E vs 6 [100%] in S, P = .043). There was a trend toward shorter intensive care unit stay and ventilation time in E group, and overall hospital stay was significantly less in the E group (48.18 ± 25.95 vs 94.00 ± 53.07 days, P = .028). Thirty-day mortality was similar between groups (E 18% vs S 16%, P = .9), but there was a trend toward improved overall survival in the E group. CONCLUSION: This is the first study to examine early initiation of RRT after LVAD implant. Early RRT was associated with shorter hospital stay, lower need for permanent RRT, and a trend toward improved survival. This practice may provide significant cost savings and should be examined further.

Screening for Asymptomatic Coronary Artery Disease in Waitlisted Kidney Transplant Candidates: A Cost-Utility Analysis.

RATIONALE & OBJECTIVE: On account of the high prevalence of cardiovascular disease in patients with kidney failure, clinical practice guidelines recommend regular screening for asymptomatic coronary artery disease (CAD) in patients on the kidney transplant waitlist. To date, the cost-effectiveness of such screening has not been evaluated. A Canadian-Australasian randomized controlled trial of screening kidney transplant candidates for CAD (CARSK) is currently is being conducted to answer this question. We conducted a cost-utility analysis to determine, before completion of the trial, the cost-effectiveness of no further screening versus regular screening for asymptomatic CAD and to evaluate potential influential variables that may affect results of the economic evaluation. STUDY DESIGN: A modeled cost-utility analysis. SETTING & POPULATION: A theoretical cohort of adult Australian and New Zealand kidney transplant candidates on the waitlist. INTERVENTION: No further screening for asymptomatic CAD versus regular protocolized screening (annual or second yearly) for CAD after kidney transplant waitlisting. OUTCOMES: Incremental cost-effectiveness ratio, reported as cost per quality-adjusted life-year (QALY). MODEL, PERSPECTIVES, & TIMEFRAME: Markov microsimulation model, health system perspective and over a lifetime horizon. RESULTS: In the base case, the incremental cost-effectiveness ratio of no further screening was $11,122 per QALY gained when compared with regular screening. No further screening increased survival by 0.49 life-year or 0.35 QALY. One-way sensitivity analyses identified the costs of transplantation in the first year and CAD prevalence as the most influential variables. Probabilistic sensitivity analyses showed that 94% of the simulations were cost-effective below a willingness-to-pay threshold of $50,000 per QALY gained. LIMITATIONS: Rates of cardiovascular events in waitlisted candidates and transplant recipients are limited in the contemporary era. The results may not be generalizable to populations outside Australia and New Zealand. CONCLUSIONS: No further screening for CAD after waitlisting is likely to be cost-effective and may improve survival. Precision around CAD prevalence estimates and health care resource use will reduce existing uncertainty.

Clinical outcomes and healthcare use associated with optimal ESRD starts.

OBJECTIVES: To assess the association between optimal end-stage renal disease (ESRD) starts and clinical and utilization outcomes in an integrated healthcare delivery system. STUDY DESIGN: Retrospective observational cohort study in 6 regions of an integrated healthcare delivery system, 2011-2013. METHODS: Propensity score techniques were used to match 1826 patients who experienced an optimal start of renal replacement therapy (initial therapy of hemodialysis via an arteriovenous fistula or graft, peritoneal dialysis, or pre-emptive transplant) to 1826 patients who experienced a nonoptimal start (hemodialysis via a central venous catheter). Outcomes included 12-month rates of sepsis, mortality, and utilization (inpatient stays, total inpatient days, emergency department visits, and outpatient visits to primary care and specialty care). RESULTS: Optimal starts were associated with a 65% reduction in sepsis (odds ratio, 0.35; 95% CI, 0.29-0.42) and a 56% reduction in 12-month mortality (hazard ratio, 0.44; 95% CI, 0.36-0.53). Optimal starts were also associated with lower utilization, except for nephrology visits. Large utilization differences were observed for total inpatient days (9.4 for optimal starts vs 27.5 for nonoptimal starts; relative rate [RR], 0.45; 95% CI, 0.38-0.52) and outpatient visits for specialty care other than nephrology or vascular surgery (12.5 vs 18.3, respectively; RR, 0.62; 95% CI, 0.53-0.74). CONCLUSIONS: Compared with patients with nonoptimal starts, patients with optimal ESRD starts have lower morbidity and mortality and less use of inpatient and outpatient care. Late-stage chronic kidney disease and ESRD care in an integrated system may be associated with greater benefits than those previously reported in the literature.

Reducing the costs of chronic kidney disease while delivering quality health care: a call to action.

The treatment of chronic kidney disease (CKD) and of end-stage renal disease (ESRD) imposes substantial societal costs. Expenditure is highest for renal replacement therapy (RRT), especially in-hospital haemodialysis. Redirection towards less expensive forms of RRT (peritoneal dialysis, home haemodialysis) or kidney transplantation should decrease financial pressure. However, costs for CKD are not limited to RRT, but also include nonrenal health-care costs, costs not related to health care, and costs for patients with CKD who are not yet receiving RRT. Even if patients with CKD or ESRD could be given the least expensive therapies, costs would decrease only marginally. We therefore propose a consistent and sustainable approach focusing on prevention. Before a preventive strategy is favoured, however, authorities should carefully analyse the cost to benefit ratio of each strategy. Primary prevention of CKD is more important than secondary prevention, as many other related chronic diseases, such as diabetes mellitus, hypertension, cardiovascular disease, liver disease, cancer, and pulmonary disorders could also be prevented. Primary prevention largely consists of lifestyle changes that will reduce global societal costs and, more importantly, result in a healthy, active, and long-lived population. Nephrologists need to collaborate closely with other sectors and governments, to reach these aims.

How a Bottom-Up Multi-Stakeholder Initiative Helped Transform the Renal Replacement Therapy Landscape in Spain.

Healthcare reforms aim to change certain parts of the health system to improve quality of care, access, or financial sustainability. Traditionally, healthcare reform is understood as an action undertaken by a government at a national or local level. However, bottom-up changes can also lead to improvements in the health system. This paper describes the efforts of a coordinated multi-stakeholder advocacy group in Spain to promote a more cost-effective and patient-centred treatment for people receiving renal replacement therapy and assesses the outcomes of their advocacy for health system financing and patient satisfaction. It concludes that bottom-up initiatives do indeed have the power to change health policy and that policy makers should pay attention to their arguments.

Healthcare costs in chronic kidney disease and renal replacement therapy: a population-based cohort study in Sweden.

OBJECTIVE: To compare healthcare costs in chronic kidney disease (CKD) stage 4 or 5 not on dialysis (estimated glomerular filtration rate <30 mL/min/1.73m2), peritoneal dialysis, haemodialysis and in transplanted patients with matched general population comparators. DESIGN: Population-based cohort study. SETTING: Swedish national healthcare system. PARTICIPANTS: Prevalent adult patients with CKD 4 or 5 (n=1046, mean age 68 years), on peritoneal dialysis (n=101; 64 years), on haemodialysis (n=460; 65 years) and with renal transplants (n=825; 52 years) were identified in Stockholm County clinical quality registers for renal disease on 1 January 2010. 5 general population comparators from the same county were matched to each patient by age, sex and index year. PRIMARY AND SECONDARY OUTCOME MEASURES: Annual healthcare costs in 2009 incurred through inpatient and hospital-based outpatient care and dispensed prescription drugs ascertained from nationwide healthcare registers. Secondary outcomes were annual number of hospital days and outpatient care visits. RESULTS: Patients on haemodialysis had the highest mean annual cost (€87 600), which was 1.49 (95% CI 1.38 to 1.60) times that observed in peritoneal dialysis (€58 600). The mean annual cost was considerably lower in transplanted patients (€15 500) and in the CKD group (€9600). In patients on haemodialysis, outpatient care costs made up more than two-thirds (€62 500) of the total, while costs related to fluids ($29 900) was the largest cost component in patients on peritoneal dialysis (51%). Compared with their matched general population comparators, the mean annual cost (95% CI) in patients on haemodialysis, peritoneal dialysis, transplanted patients and patients with CKD was 45 (39 to 51), 29 (22 to 37), 11 (10 to 13) and 4.0 (3.6 to 4.5) times higher, respectively. CONCLUSIONS: The mean annual costs were ∼50% higher in patients on haemodialysis than in those on peritoneal dialysis. Compared with the general population, costs were substantially elevated in all groups, from 4-fold in patients with CKD to 11, 29 and 45 times higher in transplanted patients and patients on peritoneal dialysis and haemodialysis, respectively.

Cost comparison of kidney transplant versus dialysis in Brazil.

This study aimed to compare the direct medical costs of renal transplantation and renal replacement therapies, specifically hemodialysis and peritoneal dialysis, from the perspective of the Brazilian Unified National Health System (SUS). Renal replacement therapies costs were based on data published in the literature. Cost items for kidney transplant were identified in a private hospital based on procedure codes used for charging the SUS, and other items were taken from the literature. In the four years covered by the study, cadaver kidney transplant generated per-patient savings of BRL 37,000 and BRL 74,000 compared to hemodialysis and peritoneal dialysis, respectively. Savings were even greater with living donor kidney transplant: BRL 46,000 and BRL 82,000 compared to hemodialysis and peritoneal dialysis, respectively. This result, together with survival and quality-of-life analyses, characterizes kidney transplant as the best clinical and financial alternative, thus supporting public policies for organ transplants in Brazil.

Predicting hospital costs for patients receiving renal replacement therapy to inform an economic evaluation.

OBJECTIVE: To develop a model to predict annual hospital costs for patients with established renal failure, taking into account the effect of patient and treatment characteristics of potential relevance for conducting an economic evaluation, such as age, comorbidities and time on treatment. The analysis focuses on factors leading to variations in inpatient and outpatient costs and excludes fixed costs associated with dialysis, transplant surgery and high cost drugs. METHODS: Annual costs of inpatient and outpatient hospital episodes for patients starting renal replacement therapy in England were obtained from a large retrospective dataset. Multiple imputation was performed to estimate missing costs due to administrative censoring. Two-part models were developed using logistic regression to first predict the probability of incurring any hospital costs before fitting generalised linear models to estimate the level of cost in patients with positive costs. Separate models were developed to predict inpatient and outpatient costs for each treatment modality. RESULTS: Data on hospital costs were available for 15,869 incident dialysis patients and 4511 incident transplant patients. The two-part models showed a decreasing trend in costs with increasing number of years on treatment, with the exception of dialysis outpatient costs. Age did not have a consistent effect on hospital costs; however, comorbidities such as diabetes and peripheral vascular disease were strong predictors of higher hospital costs in all four models. CONCLUSION: Analysis of patient-level data can result in a deeper understanding of factors associated with variations in hospital costs and can improve the accuracy with which costs are estimated in the context of economic evaluations.

Uma comparação dos custos do transplante renal em relação às diálises no Brasil / Cost comparison of kidney transplant versus dialysis in Brazil / Una comparación de los costes del trasplante renal en relación con las diálisis en Brasil

Resumo: O objetivo do presente estudo foi comparar os custos médicos diretos do transplante renal e das terapias renais substitutivas, especificamente a hemodiálise e a diálise peritoneal, sob a perspectiva do Sistema Único de Saúde (SUS). Os custos das terapias renais substitutivas foram extraídos de informações publicadas na literatura. Os itens de custo previstos do transplante renal foram identificados em um hospital privado mediante coleta dos códigos dos procedimentos utilizados para a cobrança do SUS e os demais itens extraídos da literatura. O resultado desta pesquisa indica que, no período dos quatro anos coberto por este estudo, o transplante renal de doador falecido gera uma economia, por paciente, de R$ 37 mil e R$ 74 mil em relação à hemodiálise e à diálise peritoneal, respectivamente. Quanto ao transplante renal de doador vivo, as economias são ainda maiores: R$ 46 mil e R$ 82 mil em relação à hemodiálise e à diálise peritoneal, respectivamente. Este resultado, aliado a análises de sobrevida e qualidade de vida, pode caracterizar o transplante renal como a melhor alternativa do ponto de vista financeiro e clínico, auxiliando na formulação de políticas públicas relacionadas com os transplantes de órgãos no Brasil.

Abstract: This study aimed to compare the direct medical costs of renal transplantation and renal replacement therapies, specifically hemodialysis and peritoneal dialysis, from the perspective of the Brazilian Unified National Health System (SUS). Renal replacement therapies costs were based on data published in the literature. Cost items for kidney transplant were identified in a private hospital based on procedure codes used for charging the SUS, and other items were taken from the literature. In the four years covered by the study, cadaver kidney transplant generated per-patient savings of BRL 37,000 and BRL 74,000 compared to hemodialysis and peritoneal dialysis, respectively. Savings were even greater with living donor kidney transplant: BRL 46,000 and BRL 82,000 compared to hemodialysis and peritoneal dialysis, respectively. This result, together with survival and quality-of-life analyses, characterizes kidney transplant as the best clinical and financial alternative, thus supporting public policies for organ transplants in Brazil.

Resumen: El objetivo del presente estudio fue comparar los costes médicos directos del trasplante renal y de las terapias renales substitutivas, específicamente la hemodiálisis y la diálisis peritoneal, bajo la perspectiva del Sistema Único de Salud (SUS). Los costes de las terapias renales substitutivas se extrajeron de información publicada en la literatura. Los ítems de coste previstos del trasplante renal se identificaron en un hospital privado, a partir de la recogida de códigos de procedimientos utilizados para el cobro del SUS y los demás ítems extraídos de la literatura. El resultado de esta investigación indica que, en el período de los 4 años cubierto por este estudio, el trasplante renal del donante fallecido genera un ahorro, por paciente, de R$ 37 mil y R$ 74 mil en relación al hemodiálisis y al diálisis peritoneal, respectivamente. En cuanto al trasplante renal del donante vivo, los ahorros son incluso mayores: R$ 46 mil y R$ 82 mil, en relación a la hemodiálisis y a la diálisis peritoneal, respectivamente. Este resultado, junto con análisis de supervivencia y calidad de vida, puede caracterizar el trasplante renal como la mejor alternativa desde el punto de vista financiero y clínico, auxiliando en la formulación de políticas públicas relacionadas con los trasplantes de órganos en Brasil.

Understanding cost of care for patients on renal replacement therapy: looking beyond fixed tariffs.

BACKGROUND: In a number of countries, reimbursement to hospitals providing renal dialysis services is set according to a fixed tariff. While the cost of maintenance dialysis and transplant surgery are amenable to a system of fixed tariffs, patients with established renal failure commonly present with comorbid conditions that can lead to variations in the need for hospitalization beyond the provision of renal replacement therapy. METHODS: Patient-level cost data for incident renal replacement therapy patients in England were obtained as a result of linkage of the Hospital Episodes Statistics dataset to UK Renal Registry data. Regression models were developed to explore variations in hospital costs in relation to treatment modality, number of years on treatment and factors such as age and comorbidities. The final models were then used to predict annual costs for patients with different sets of characteristics. RESULTS: Excluding the cost of renal replacement therapy itself, inpatient costs generally decreased with number of years on treatment for haemodialysis and transplant patients, whereas costs for patients receiving peritoneal dialysis remained constant. Diabetes was associated with higher mean annual costs for all patients irrespective of treatment modality and hospital setting. Age did not have a consistent effect on costs. CONCLUSIONS: Combining predicted hospital costs with the fixed costs of renal replacement therapy showed that the total cost differential for a patient continuing on dialysis rather than receiving a transplant is considerable following the first year of renal replacement therapy, thus reinforcing the longer-term economic advantage of transplantation over dialysis for the health service.

End-of-life matters in chronic renal failure.

PURPOSE OF REVIEW: The population considered eligible for dialysis has expanded dramatically over the past 4 decades, so that a significant proportion of patients receiving renal replacement therapy are elderly, frail and infirm. These patients have an extremely limited life expectancy and suffer from significant symptom burden, similar to patients with other end-stage organ failure or cancer. As dialysis has been offered more broadly, it is now initiated earlier than in decades past, further adding to cost and patient burden. RECENT FINDINGS: The trend toward more expansive and intensive care has not been corroborated by robust data. In response, an increasing number of studies has focused on establishing reasonable limits to renal replacement therapy. Multiple authors have explored the role of conservative kidney management for high-risk dialysis patients as an alternative to dialysis, which may offer similar survival and improved quality of life in certain populations. For those who chose dialysis, deferring initiation until the patient becomes symptomatic may be a reasonable. Evidence-based symptom management guidelines for dialysis patients remain largely absent, with few proven approaches. Hospice and palliative care resources remain underutilized. SUMMARY: For a subset of dialysis patients, palliative care and conservative kidney management are appropriate and underutilized. VIDEO ABSTRACT: http://links.lww.com/COSPC/A8

Série histórica de custos com terapia de substituição renal no município do Rio de Janeiro (1995-2009) / Time series of costs of renal replacement therapy in Rio de Janeiro city (1995-2009)

Objetivou-se avaliar a tendência temporal do custo total de terapia de substituição renal e a proporção entre custo e solicitações de Autorizações de Procedimentos Ambulatoriais de Alta Complexidade/Custo no município do Rio de Janeiro, entre 1995 e 2009, em totais e segundo prestador. Estudo quantitativo, descritivo, tipo série temporal. Utilizaram-se informações referentes aos valores e quantidades de autorizações de procedimentos de alta complexidade para terapia de substituição renal por ano, disponíveis no DATASUS, coletadas entre fevereiro e março de 2011. Observou-se tendência crescente para o custo total e o total de autorizações destes procedimentos (y=3,8414x + 16,904, R2=0,9665 e y=14519x + 299719, R2=0,8835, respectivamente). Há uma diferença estatisticamente significativa (p<0,001) da variação da tendência quando comparados os serviços públicos e os privados. Conclui-se que há uma tendência em programar cada vez mais serviços nos hospitais públicos, tornando crescente a demanda por profissionais qualificados para atuação na área.

Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease.

BACKGROUND: There are limited data on the outcomes of elderly patients with chronic kidney disease undergoing renal replacement therapy or conservative management. AIMS: We aimed to compare survival, hospital admissions and palliative care access of patients aged over 70 years with chronic kidney disease stage 5 according to whether they chose renal replacement therapy or conservative management. DESIGN: Retrospective observational study. SETTING/PARTICIPANTS: Patients aged over 70 years attending pre-dialysis clinic. RESULTS: In total, 172 patients chose conservative management and 269 chose renal replacement therapy. The renal replacement therapy group survived for longer when survival was taken from the time estimated glomerular filtration rate <20 mL/min (p < 0.0001), <15 mL/min (p < 0.0001) and <12 mL/min (p = 0.002). When factors influencing survival were stratified for both groups independently, renal replacement therapy failed to show a survival advantage over conservative management, in patients older than 80 years or with a World Health Organization performance score of 3 or more. There was also a significant reduction in the effect of renal replacement therapy on survival in patients with high Charlson's Comorbidity Index scores. The relative risk of an acute hospital admission (renal replacement therapy vs conservative management) was 1.6 (p < 0.05; 95% confidence interval = 1.14-2.13). A total of 47% of conservative management patients died in hospital, compared to 69% undergoing renal replacement therapy (Renal Registry data). Seventy-six percent of the conservative management group accessed community palliative care services compared to 0% of renal replacement therapy patients. CONCLUSIONS: For patients aged over 80 years, with a poor performance status or high co-morbidity scores, the survival advantage of renal replacement therapy over conservative management was lost at all levels of disease severity. Those accessing a conservative management pathway had greater access to palliative care services and were less likely to be admitted to or die in hospital.

Estimating the financial cost of chronic kidney disease to the NHS in England.

BACKGROUND: Chronic kidney disease (CKD) is a major challenge for health care systems around the world, and the prevalence rates appear to be increasing. We estimate the costs of CKD in a universal health care system. METHODS: Economic modelling was used to estimate the annual cost of Stages 3-5 CKD to the National Health Service (NHS) in England, including CKD-related prescribing and care, renal replacement therapy (RRT), and excess strokes, myocardial infarctions (MIs) and Methicillin-Resistant Staphylococcus Aureus (MRSA) infections in people with CKD. RESULTS: The cost of CKD to the English NHS in 2009-10 is estimated at £ 1.44 to £ 1.45 billion, which is ≈ 1.3% of all NHS spending in that year. More than half this sum was spent on RRT, which was provided for 2% of the CKD population. The economic model estimates that ≈ 7000 excess strokes and 12 000 excess MIs occurred in the CKD population in 2009-10, relative to an age- and gender-matched population without CKD. The cost of excess strokes and MIs is estimated at £ 174-£ 178 million. CONCLUSIONS: The financial impact of CKD is large, with particularly high costs relating to RRT and cardiovascular complications. It is hoped that these detailed cost estimates will be useful in analysing the cost-effectiveness of treatments for CKD.

Geriatric nephrology: a paradigm shift in the approach to renal replacement therapy.

The population of elderly individuals diagnosed with CKD continues to grow. Many have multiple comorbid conditions that will impact life expectancy as well as decisions about whether to pursue renal replacement therapy. Nephrologists are uniquely positioned to assist their patients and caregivers in this regard and spend considerable time counseling them about the benefits and risks associated with dialysis therapy. This article presents an overview of many of the issues facing nephrologists, and provides tools to assist busy clinicians in helping their elderly patients in deciding whether to consider dialysis or intensive, nondialysis care.

Tratamento da infecção pelo vírus da hepatite C em candidatos a transplante renal submetidos a diálise: impacto orçamentário no SUS / Hepatitis C treatment in patients on dialysis awaiting renal transplantation: a budget impact analysis

Trata-se de uma análise de impacto orçamentário derivada dos resultados do estudo "Custo-efetividade do tratamento da infecção pelo vírus da hepatite C em candidatos a transplante renal submetidos a diálise". Teve como objetivo estimar o impacto orçamentário da ampliação da oferta do tratamento da infecção pelo vírus da hepatite C (VHC) para candidatos a transplante renal. Para tal, foi construído um modelo de Markov, a fim de estimar o custo médio do tratamento de diferentes proporções da população-alvo. Foram estimados os casos prevalentes e incidentes da infecção na população em diálise, candidata a transplante renal, em um horizonte de tempo de dez anos. Com base nestas estimativas, foi calculado o valor a ser despendido pelo SUS para tratar a população-alvo em três cenários diferenciados, caracterizados pela proporção da população submetida ao tratamento. Os valores encontrados foram comparados com o gasto do sistema para garantia de terapias de substituição renal no período de um ano, identificando-se que o custo do tratamento de toda a população candidata a transplante, infectada pelo VHC, corresponde a 0,3 por cento do valor despendido com TRS pelo SUS.

This is an analyses of the budget impact derived from the cost-effectiveness study on the hepatitis C treatment in candidates for renal transplantation under dialysis. It aims to estimate the budget impact of an offer of hepatitis C treatment for all candidates for renal transplantation. A Markov model was developed to estimate the mean cost for treatment of distinct proportions of the target population. The prevalence and incidence of hepatitis C in the candidates for renal transplantation in the dialysis population was also estimated in a horizon of ten years. Based on these estimative, we calculate the amount needed for treatment of this population in three distinct scenarios characterized by a proportion of the population under treatment. The values were compared with the expense of the system to guarantee renal replacement therapies in one year, identifying the cost of treatment of all candidates for transplant, infected with HCV, corresponding to 0.3 percent of the amount spent with renal transplantation within the SUS.