Abstract
BackgroundChronic kidney disease (CKD) is the focus of recent national policy efforts; however, decision makers must account for multiple therapeutic options, comorbidities and complications. The objective of the Chronic Kidney Disease model is to provide guidance to decision makers. We describe this model and give an example of how it can inform clinical and policy decisions.MethodsMonte Carlo simulation of CKD natural history and treatment. Health states include myocardial infarction, stroke with and without disability, congestive heart failure, CKD stages 1-5, bone disease, dialysis, transplant and death. Each cycle is 1 month. Projections account for race, age, gender, diabetes, proteinuria, hypertension, cardiac disease, and CKD stage. Treatment strategies include hypertension control, diabetes control, use of HMG-CoA reductase inhibitors, use of angiotensin converting enzyme inhibitors, nephrology specialty care, CKD screening, and a combination of these. The model architecture is flexible permitting updates as new data become available. The primary outcome is quality adjusted life years (QALYs). Secondary outcomes include health state events and CKD progression rate.ResultsThe model was validated for GFR change/year -3.0 ± 1.9 vs. -1.7 ± 3.4 (in the AASK trial), and annual myocardial infarction and mortality rates 3.6 ± 0.9% and 1.6 ± 0.5% vs. 4.4% and 1.6% in the Go study. To illustrate the model's utility we estimated lifetime impact of a hypothetical treatment for primary prevention of vascular disease. As vascular risk declined, QALY improved but risk of dialysis increased. At baseline, 20% and 60% reduction: QALYs = 17.6, 18.2, and 19.0 and dialysis = 7.7%, 8.1%, and 10.4%, respectively.ConclusionsThe CKD Model is a valid, general purpose model intended as a resource to inform clinical and policy decisions improving CKD care. Its value as a tool is illustrated in our example which projects a relationship between decreasing cardiac disease and increasing ESRD.
Highlights
Chronic kidney disease (CKD) is the focus of recent national policy efforts; decision makers must account for multiple therapeutic options, comorbidities and complications
Chronic kidney disease (CKD) affects 13% of the US population and its incidence is increasing with the rise in major CKD risk factors, hypertension and diabetes[1]
Which interventions provide improved health outcomes, when considering potential adverse effects, uncertain effectiveness, and the likelihood that events such as myocardial infarction (MI) may be more likely than end-stage renal disease (ESRD)? Do the health benefits come at an acceptable cost? How do providers account for both the wide variety of potential interventions and the dynamic epidemiology of CKD, which involves multiple, changing risk factors and competing comorbidities?
Summary
Chronic kidney disease (CKD) is the focus of recent national policy efforts; decision makers must account for multiple therapeutic options, comorbidities and complications. The objective of the Chronic Kidney Disease model is to provide guidance to decision makers. We describe this model and give an example of how it can inform clinical and policy decisions. One strategy to avoid this inefficiency is to create a model sanctioned by a major governmental agency, professional organization, or other accountable entity. Another strategy is to develop a general-purpose, publicly available model. These models are flexible enough to address a wide variety of clinically-and policy-relevant questions and are freely available to researchers and clinicians. The notion is that such a model could serve to promote a more informed decision-making process by allowing for consistent evaluation of various treatment strategies, and ongoing feedback from users who are encouraged to participate in the continuous improvement of the model in a public forum
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