Cost-effective treatment modalities for reducing morbidity associated with chronic kidney disease

Abstract

Chronic kidney disease (CKD) is a worldwide health problem with increasing prevalence and incidence. Guidelines suggest that early referral to a nephrologist to manage advanced stage (4+) patients with CKD is an effective treatment strategy, with earlier stage patients best managed through primary care physicians. Should patients with CKD progress to total kidney failure, several therapies are available that vary widely in costs. Kidney transplantation offers the lowest costs and highest quality of life, followed in ascending order of costs by peritoneal dialysis, home hemodialysis and facility-based hemodialysis. Earlier detection of CKD may prevent progression to kidney failure, and accurate risk prediction of end-stage kidney failure may improve clinical planning, outcomes and resource allocation.

Keywords:

• chronic kidney disease
• cost–effectiveness
• dialysis
• economic analysis
• hemodialysis
• home hemodialysis
• peritoneal dialysis
• screening
• transplantation
• treatment modalities

Financial & competing interests disclosure

TW Ferguson is supported by a Graduate Studentship from Research Manitoba. N Tangri is supported by the KRESCENT New Investigator Award and the MHRC Establishment Award. The KRESCENT New investigator award is a joint initiative of the Kidney Foundation of Canada, Canadian Institute of Health Research and the Canadian Society of Nephrology. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• CKD is defined as the presence of kidney damage, such as elevated urine albumin (proteinuria), or decreased kidney function measured as estimated glomerular filtration rate less than 60 ml/min per 1.73 m².

• Interprofessional nephrology teams should be used to manage patients with advanced CKD: those who have an eGFR that falls below 30 ml/min per 1.73 m² or with highly increased persistent albuminuria.

• Most patients with CKD will never require kidney replacement therapy, with patients being an estimated 13× more likely to die before reaching this point.

• For those who do reach kidney failure, several modalities of dialysis treatment are available. Facility hemodialysis is the most costly of the dialysis interventions (roughly US$70,000 per patient, per year), followed by home hemodialysis (US$40,000–US$50,000 per patient, per year after the first year), and peritoneal dialysis is the least expensive (US$30,000–US$50,000 per patient, per year).

• Transplantation is the least costly (US$35,500 per patient, per year after the first year) and more effective of the kidney replacement options. Patients on this modality tend to have a higher overall quality of life (utility of 0.80 vs a utility of 0.55–0.65 for hemodialysis patients). Unfortunately, due to frail patients unable to complete the transplantation procedure and a lack of available organs to satiate all demand, this treatment option is not feasible in all cases.

• Earlier detection of CKD may delay or prevent many complications, reduce overall mortality, and slow progression to kidney failure requiring these expensive dialysis treatments. Readily available blood and urine tests can be used to accomplish this. Screening in patients with diabetes and/or hypertension has been shown to be cost-effective; however, screening in the general population has mixed findings with respect to cost–effectiveness.

• Clinical risk prediction, using models such as the Kidney Failure Risk Equation, can be used to efficiently allocate resources and plan appropriate clinical care for patients with late-stage CKD. Improved decision support implementing these tools in electronic medical records may help practitioners decide on appropriate care pathways for their patients.

• Although patient choice has often been a primary consideration for choosing dialysis modalities, in an era of increasing fiscal constraints, applying healthcare policies aimed at promoting appropriately assigned home-based dialysis and developing eligibility criteria for more expensive facility-based hemodialysis may be required to manage increasing end-stage kidney failure-related costs.

• Despite exciting potential research in wearable artificial kidneys and implantable tissue, the provision of dialysis will likely be a mainstay therapy for many years to come and allocation of resources needs to be managed efficiently.

Notes