Ultrapure versus standard dialysate: A cost-benefit analysis.

Low-level bacterial and endotoxin contamination of water used to generate dialysate propagates chronic inflammation in patients with a wide-range of potential adverse consequences, including erythropoietin hyporesponsiveness. Advancements in hemodialysis systems now allow for the generation of ultrapure dialysate that has lower bacterial and endotoxin levels than the standard dialysate. The cost associated with ultrapure dialysate is thought to be a major barrier to its widespread adoption. In this report, we conduct a cost-benefit analysis examining the excess cost of generating ultrapure dialysate and the potential cost saving from a lower erythropoietin dose requirement. Our analysis suggests a potential cost saving of approximately $371 to $425 million per year with full adoption of ultrapure dialysate in the United States.

Effectiveness and cost-efficacy of phosphate binders in hemodialysis.

OBJECTIVES: Worldwide, incidence rates of chronic renal insufficiency have clearly increased over the past decade, especially in people of older age. Hyperphosphatemia is the strongest independent risk factor for mortality in renal patients. In order to reduce serum phosphate concentrations to recommended values, phosphate binders (P binders) are used to bind ingested phosphate in the digestive tract. Besides the traditional therapies with calcium and aluminium salts, sevelamer and lanthanum represent recent developments on the market. The purpose of the present health technology assessment (HTA) report was to compare the effectiveness and safety of different P binders in patients with chronic renal insufficiency. METHODS: Based on a systematic literature search followed by a two-part selection process with predefined criteria 18 publications were included in the assessment. RESULTS: All P binders effectively controlled serum phosphate, calcium and parathyroid hormone concentrations. The numbers of hypercalcemic episodes were higher when using calcium-containing P binders compared to sevelamer and lanthanum. Regarding mortality rate, cardiovascular calcification and bone metabolism no definite conclusions could be drawn; however, sevelamer seemed to be more effective than calcium in certain patient subgroups, such as older patients and patients with preexisting arterial calcification. CONCLUSIONS: From a medical point of view, sevelamer showed superiority over calcium-containing P binders at least for special indications.

Recycling wastewater after hemodialysis: an environmental analysis for alternative water sources in arid regions.

Water is a vital aspect of hemodialysis. During the procedure, large volumes of water are used to prepare dialysate and clean and reprocess machines. This report evaluates the technical and economic feasibility of recycling hemodialysis wastewater for irrigation uses, such as watering gardens and landscape plantings. Water characteristics, possible recycling methods, and production costs of treated water are discussed in terms of the quality of the generated wastewater. A cost-benefit analysis is also performed through comparison of intended cost with that of seawater desalination, which is widely used in irrigation.

[Phosphorus (P) chelant in dialysis: efficacy and cost. Peritoneal dialysis solutions]. / Quelantes de fósforo (P) en diálisis: eficacia y coste. Soluciones de diálisis peritoneal.

Sevelamer use has a high prevalence, and half of patients are treated with this noncalcium binder. Two randomized studies appeared in 2007 that compared the efficacy of sevelamer over calcium salts. In the more statistically potent of the two studies, no differences were found in mortality between the sevelamer and calcium groups, except for a benefit in favor of sevelamer in patients older than 65 years. In the other less statistically potent study, lower mortality was observed in the sevelamer group. Both studies have various deficiencies and a timely meta-analysis of the two studies appearing that same year concluded that there was no significant evidence demonstrating a superior efficacy of sevelamer over calcium salts. Therefore, generalized extension of its use as a first-line binder is not recommended. However, its use can be assessed in specific clinical situations. With regard to the cost-benefit ratio, as there is no evidence that greater clinical benefits are obtained with sevelamer than with calcium salts, prudence and moderation in its use are needed because of the high cost/benefit ratio demonstrated. Otherwise, we will contribute to increasing the already very high treatment cost in these patients, with one of the highest costs per life year gained in medicine. The cost/benefit ratio of sevelamer remains unattractive from an economic point of view, even if dialysis and transplant are excluded in these patients.

Preparation times and costs for various solutions used for continuous renal replacement therapy.

PURPOSE: Results of a study to determine time and cost requirements for final preparation of continuous renal replacement therapy (CRRT) products are reported. METHODS: A 3-phase observational study was conducted at a tertiary care university hospital to evaluate costs associated with manual addition of phosphate and/or potassium to 3 commercial 5-L CRRT products. In the first phase of the study, pharmacy workflow processes for solution preparation were established; in the second phase, pharmacist and pharmacy technician time spent in the CRRT workflow and all materials used were observed and recorded. In the third phase, time and personnel requirements were analyzed in economic terms to estimate final preparation costs. RESULTS: Through direct observation over 35 days, the CRRT workflow was observed and work times recorded for 511 bag preparations. The main cost contributors were the base CRRT solution and electrolyte additive prices. Technician compounding time differed substantially by solution brand and the need for electrolyte addition. Pharmacist verification time did not differ meaningfully by product. CONCLUSION: Preparation and verification of premade CRRT solutions that contained physiological electrolyte concentrations required less technician and pharmacist time than solutions that needed addition of electrolytes in the pharmacy. Personnel costs, which were a small part of the total cost of dispensed CRRT bags, were higher for technicians than pharmacists. The baseline costs of the solutions and the electrolyte additives, if needed, were the main contributors to total cost.

A strategy to reduce inflammation and anemia treatment's related costs in dialysis patients.

This is a post-hoc analysis evaluating erythropoiesis stimulating agents' (ESA) related costs while using an additional ultrafilter (Estorclean PLUS) to produce ultrapure dialysis water located within the fluid pathway after the treatment with reverse osmosis and before the dialysis machine. Twenty-nine patients (19 treated with epoetin alfa and 10 with darboepoetin alfa) were included in the analysis. We showed to gain savings of 210 € per patient (35 € per patient each month) with epoetin alfa during the experimental period of 6 months, compared to the control period and of 545 € per patient (90 € per patient each month) with darboepoetin alfa. Estorclean PLUS had a cost of 600 € (25 € per month per each patient) and was used for 6 months. Intravenous iron therapy with sodium ferrigluconate had a cost of 0,545 €/62,5 mg. In conclusion, during the experimental period with the use of Estorclean, we obtained global savings of 11 € per patient per month with epoetin alfa and 30 € per patient per month with darboepoetin alfa to treat anemia in dialysis patients.

Metabolic complications during regional citrate anticoagulation in continuous venovenous hemodialysis: single-center experience.

BACKGROUND: Regional anticoagulation with trisodium citrate is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) in patients at a high risk of bleeding. In a prospective, observational study we compared an established regional citrate anticoagulation protocol [Mehta R et al: Kidney Int 1990;38:976-981] versus a standard heparin anticoagulation protocol focusing on acid-base and electrolyte derangements as well as on cost effectiveness. METHODS AND RESULTS: 209 patients were included in the study. In 37 patients, citrate was used as the sole anticoagulant, 87 patients received low-dose heparin plus citrate, and 85 patients received only heparin as anticoagulant. A customized dialysate solution was used for citrate-anticoagulated CRRT (no buffer, no calcium, reduced sodium concentration). Filter life was significantly higher during citrate anticoagulation compared to heparin anticoagulation (80.2 +/- 60 vs. 30.2 +/- 32 h; p < 0.001). No difference was found between citrate and citrate-heparin anticoagulation (p = 0.310). Metabolic alkalosis was observed in more than 50% of patients on citrate anticoagulation. Alkalosis developed within the first 72 h after initiating treatment and could be reversed in almost all cases by increasing the dialysate flow rate. Hypercalcemia was observed in 13 patients on citrate anticoagulation. Patients with impaired liver function were particularly at risk. Systemic hypocalcemia, hypernatremia, and anion gap acidosis were not observed. Citrate anticoagulation was well tolerated hemodynamically. A longer filter life during citrate anticoagulation translated into a significant cost reduction compared to standard heparin anticoagulation (p < 0.01). CONCLUSION: Regional anticoagulation with trisodium citrate in combination with a customized calcium-free dialysate is a safe and effective alternative to a heparin-based anticoagulation regimen.