Dialysis Costs Research Articles

Medical costs for managing chronic kidney disease and related complications in patients with chronic kidney disease and type 2 diabetes.

To provide cost estimates for chronic kidney disease (CKD) management and major CKD complications among patients with CKD and type 2 diabetes (T2D). A retrospective cohort study of 52,599 adults with CKD and T2D using Optum Clinformatics claims data from 2014 to 2019. Medical costs associated with CKD management, renal replacement therapies (RRTs), major CKD complications (eg, myocardial infarction, stroke, heart failure, atrial fibrillation, and hyperkalemia), and death were estimated using generalized estimating equations adjusting for baseline demographics, complications, and medical costs. Costs for CKD management, RRT, and major CKD complications were assessed in 4-month cycles. Mortality costs were assessed in the month before death. The estimated 4-month CKD management costs ranged from $7725 for stage I to II disease to $11,879 for stage V (without RRT), with high additional costs for dialysis and kidney transplantation ($87,538and $124,271, respectively). The acute event costs were $31,063 for heart failure, $21,087 for stroke, and $21,016 for myocardial infarction in the first 4 months after the incident event, which all decreased substantially in subsequent 4-month cycles. The acute event costs of atrial fibrillation and hyperkalemia were $30,500 and $31,212 with hospitalization, and $5162 and $1782 without. The costs associated with cardiovascular-related death, renal-related death, and death from other causes were $17,031, $12,605, and $9900, respectively. Management of CKD and its complications incurs high medical costs for patients with CKD and T2D. Results from this study can be used to quantify the economic profile of emerging treatments and inform decision-making.

Towards prevention of ischemia-reperfusion kidney injury: Pre-clinical evaluation of 6-chromanol derivatives and the lead compound SUL-138✰

Acute kidney injury (AKI) is a global healthcare burden attributable to high mortality and staggering costs of dialysis. The underlying causes of AKI include hypothermia and rewarming (H/R), ischemia/reperfusion (I/R), mitochondrial dysfunction and reactive oxygen species production. Inspired by the mechanisms conferring organ protection in hibernating hamster, 6-chromanol derived compounds were developed to address the need of effective prevention and treatment of AKI. Here we report on the pre-clinical screening of 6-chromanol leads that confer protection during I/R to select compounds with favorable profiles for clinical testing in AKI. A library of 6-chromanols (n = 63) was screened in silico for pharmacochemical properties and druggability. Selected compounds (n = 15) were screened for the potency to protect HEK293 cells from H/R cell death and subjected to a panel of in vitro safety assays. Based on these parameters, SUL-138 was selected as the lead compound and was found to safeguard kidney function and decrease renal injury after I/R in rats. The compound was without cardiovascular or respiratory effects in vivo. SUL-138 pharmacokinetics of control animals (mouse, rat) and those undergoing I/R (rat) was identical, showing a two-phase elimination profile with terminal half-life of about 8 h. Collectively, our phenotype-based screening approach led to the identification of 3 candidates for pre-clinical studies (5%, 3/64). SUL-138 emerged from this small-scale library of 6-chromanols as a novel prophylactic for AKI. The presented efficacy and safety data provide a basis for future development and clinical testing. Section assignments: Drug discovery and translational medicine, renal, metabolism Significance statement: Based on in silico druggability parameters, a 63 compound 6-chromanol library was narrowed down to 15 compounds. These compounds were subjected to phenotypical screening of cell survival following hypothermia damage and hit compounds were identified. After subsequent assessment of in vivo efficacy, toxicity, pharmacokinetics, and cardiovascular and respiratory safety, SUL-138 emerged as a lead compound that prevented kidney injury after ischemia/reperfusion and demonstrated a favorable pharmacokinetic profile unaffected by renal ischemia.

Dialysis and Total Health Care Costs in the United States and Worldwide: The Financial Impact of a Single-Payer Dominant System in the US.

Significance Statement In the United States, dialysis provision is an example of a robust, single-payer dominant system with cost containment. When compared with the cost of dialysis in other countries, Medicare dialysis costs in the United States as a function of overall health care expenditures are approximately $60,000 per patient less than expected, likely due to substantial cost containment imposed by Medicare as the dominant payer.

Sustainability of Chronic Kidney Disease Care


 Strategies to contain the cost of chronic kidney disease (CKD) care and to improve patient outcomes were found across the continuum of care, from prevention and early disease management through later-stage interventions such as conservative management, dialysis, and transplantation. A variety of health system strategies, including funding reform, were identified to help support and enable sustainable CKD care.
 For those at risk of CKD or in early stages of the disease, public health interventions to support healthy behaviours and ensure access to primary health care seem crucial to preventing or delaying disease progression.
 For later-stage patients requiring renal replacement therapy, enhancing access to transplantation and home-based dialysis has the potential to reduce costs while improving outcomes and quality of life. Conservative management without dialysis is an option for those who may not be good candidates for renal replacement therapy or who wish to choose a less-invasive care option.
 From a health system policy perspective, funding reform may be warranted to enhance team-based CKD care with good continuity. Policy-makers should also consider the ways in which improving financial supports for caregivers, providing travel and expense reimbursement for home dialysis patients and living organ donors, and providing support for utility and ancillary costs of home dialysis could incentivize sustainable CKD care.

Do remote dialysis services really cost more? An economic analysis of hospital and dialysis modality costs associated with dialysis services in urban, rural and remote settings

BackgroundRates of end-stage kidney disease in Australia are highest in the Northern Territory (NT), with the burden of disease heaviest in remote areas. However, the high cost of delivering dialysis services in remote areas has resulted in centralisation, requiring many people to relocate for treatment. Patients argue that treatment closer to home improves health outcomes and reduces downstream healthcare use. Existing dialysis cost studies have not compared total health care costs associated with treatment in different locations.ObjectiveTo estimate and compare, from a payer perspective, the observed health service costs (all cause hospital admissions, emergency department presentations and maintenance dialysis) associated with different dialysis models in urban, rural and remote locations.MethodsUsing cost weights attributed to diagnostic codes in the NT Department of Health’s hospital admission data set (2008–2014), we calculated the mean (SD) total annual health service costs by dialysis model for 995 dialysis patients. Generalized linear modeling with bootstrapping tested the marginal cost differences between different explanatory variables to estimate ‘best casemix’/‘worst casemix’ cost scenarios.ResultsThe mean annual patient hospital expenditure was highest for urban models at $97 928 (SD $21 261) and $43 440 (SD $5 048) and lowest for remote at $19 584 (SD $4 394). When combined with the observed maintenance dialysis costs, expenditure was the highest for urban models at $148 510 (SD $19 774). The incremental cost increase of dialysing in an urban area, compared with a rural area, for a relocated person from a remote area, was $5 648 more and increased further for those from remote and very remote areas to $10 785 and $15 118 respectively.ConclusionsThis study demonstrates that dialysis treatment in urban areas for relocated people has health and cost implications that maybe greater than the cost of remote service delivery. The study emphasises the importance of considering all health service costs and cost consequences of service delivery models.Key points for decision makersRelocation for dialysis treatment has serious health and economic consequences. Relocated people have low dialysis attendance and high hospital costs in urban areas. While remote dialysis service models are more expensive than urban models, the comparative cost differences are significantly reduced when all health service costs are included. The delivery of equitable and accessible dialysis service models requires a holistic approach that incorporates the needs of the patient; hence dialysis cost studies must consider the full range of cost impacts beyond the dialysis treatments alone.

The Importance of the World Kidney Day World Kidney Day - 11 March 2021 - Living Well with Kidney Disease.

World Kidney Day (WKD) is a global campaign to raise awareness of the importance of our kidneys to overall health and to reduce the frequency and impact of kidney disease and associated health problems worldwide. Kidney disease is a non-communicable disease (NCD) and currently affects around 850 million people worldwide. One in ten adults has chronic kidney disease (CKD). The global burden of CKD is increasing, and is projected to become the 5th most common cause of years of life lost globally by 2040. CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume 2-3% of the annual healthcare budget in high-income countries. Crucially, kidney disease can be prevented and progression to end-stage kidney disease can be delayed with appropriate access to basic diagnostics and early treatment. This year World Kidney Day continues to raise awareness of the increasing burden of kidney diseases worldwide and to strive for kidney health for everyone, everywhere. During the pandemic with COVID 19 patients kidneys are also damaged, apart from the respiratory tract and other organs. It can lead to an increase in acute renal failure and consequent chronic kidney insufficiency, as well as number of deaths. Therefore, it is important to evaluate the renal function in each patient with COVID 19 virus. In the Republic of North Macedonia from 2006 to present day nephrologists and other medical personnel devoted to the early diagnosis, prevention and treatment of renal disease have participated in the activities of the World Kidney Day. These activities were supported by the Macedonian Society of Nephrology, Dialysis, Transplantation and Artificial Organs, the Department of Nephrology at the Medical Faculty, the Macedonian Academy of Sciences and Arts, the Government of the Republic of North Macedonia, non-governmental nephrology organizations (NEFRON) and the media. There were lectures and presentation devoted to the various theme of the WKD, publications in journals, as well as activities for examination of the renal function of patients in the medical centers. The activities during the WKD contributed to the improvement of the nephrological protection of the citizens of the Republic of N. Macedonia.

Assessing the Potential and Necessity for Kidney Transplantation in the Democratic Republic of the Congo.

Assessing the Potential and Necessity for Kidney Transplantation in the Democratic Republic of the Congo.

Economic Impact of Home Hemodialysis

Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.

Economic costs of hospitalisation and length of stay in diabetes with coexisting hypertension with correlation to laboratory investigations: Where does India stand? A 5-year ground report.

The coexistence of diabetes mellitus (DM) and hypertension (HTN) worsens clinical outcomes and contributes to increased morbidity and mortality. This study aims to analyse the length of stay and healthcare costs by calculating the direct and indirect costs of diabetes with coexisting hypertension in North India. A prospective observational study was conducted atthe medicine department of the three different hospitals. The patients' mean age was (M=53.8, SD=11.5) years. Out of 1914 patients, 53.65% were female. Our study revealed that the median cost of medical supplies and equipment was 21.2 $. The median cost of dialysis was 47.5 $; the median cost of hospitalisation was 142.6 $. The treatment's median direct cost was 188.5 $, followed by the overall median cost of 295.6 $. The maximum overall cost of treatment was observed at 603.9 $. It was observed that maximum LOS was 14days for patients having BPS between 140 and 159mmHg and BPD between 110 and 119mmHg, and minimum LOS was found 3.5days. The present study highlighted that diabetes coexisting hypertension poses a high-economic burden on patients. This study explored that highly significant result for BPS, BPD, FBS and HbA1 c, whereas the significant results were obtained when RBS is compared with LOS and treatment costs. Our study concluded that mean difference of 9.24 $ in patients having FBS was 261-290mg/dL and >290mg/dL. The LOS is increased by 6.57days for patients with BPS between 140 and 159mmHg compared with BPS between 180 and 209 and above mmHg, which lowers treatment costs by -21.31$.

Burden of Renal Events Associated with Nonsteroidal Anti-inflammatory Drugs in Patients with Osteoarthritis and Chronic Low Back Pain: A Retrospective Database Study.

IntroductionNonsteroidal anti-inflammatory drugs (NSAIDs) have long-term benefits but are limited by side effects. We assessed the health and economic burden of renal events associated with NSAID use in patients with osteoarthritis (OA) and/or chronic low back pain (CLBP).MethodsThis retrospective, large-scale, medical claims database study of Japanese patients receiving NSAIDs for OA and/or CLBP between 2009 and 2018 assessed the incidence of renal events and effect of treatment duration, mode of administration, and usage consistency of NSAIDs.ResultsOf 180,371 patients, NSAIDs were prescribed as first-line analgesics in 89.3%. Incidence per 10,000 person-years (95% confidence interval [CI]) for renal events was 23.46 (21.84–25.08) and for progression of chronic kidney disease (CKD) was 267.12 (189.93–344.32). Longer treatment duration (> 1 to ≤ 3 years, risk ratio [RR] 1.32, 95% CI 1.12–1.54; P = 0.0007; > 3 to ≤ 5 years, RR: 1.38, 95% CI 1.04–1.84; P = 0.0254 vs. < 1 year) and consistent use (RR: 1.24, 95% CI 0.99–1.55; P = 0.0595) increased the risk of renal events but the latter did not reach statistical significance. The risk was similar in patients using patch/oral NSAIDs and high in elderly patients and in those with diabetes, hypertension, and other cardiovascular disease. Following a renal event, median 1-year cost of drug treatment was $27.90; hospitalization, $1779.40; and dialysis, $33,018.40.ConclusionsRisk of renal events significantly increased with prolonged and consistent NSAID use (irrespective of mode of administration), with age, and in patients with certain comorbidities. Careful NSAID use is recommended in patients with CKD and those at high risk for CKD.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-020-00233-w.

Evaluating the impact of upstream and downstream interventions on chronic kidney disease and dialysis care: a simulation analysis

AbstractAn ageing population, with increasing prevalence of diabetes and hypertension, is expected to increase the number of people with chronic kidney disease (CKD) and end‐stage renal disease (ESRD) needing dialysis. This paper explores the impact of upstream and downstream interventions on the future number of CKD, ESRD patients needing dialysis, and the cost of dialysis. A system dynamics model was developed based on Singapore national data. Results indicate that under the base case scenario the number of people with CKD is projected to increase from 437,338 in 2020 to 489,049 by 2040. As a result, the number of patients requiring dialysis is projected to increase from 7669 in 2020 to 10,516 by 2040. The cost of dialysis care, under the base case, is projected to increase from S$417.08 million in 2020 to S$907.01 million by 2040. The policy experiments show that a combined policy will cumulatively save S$1.042 billion from 2020 to 2040. © 2021 System Dynamics Society.

Glycemic Control and Self-Care Practice Among Adult Patients With Diabetes Mellitus: Cross-Sectional Study Conducted in Dawro Tercha Hospital, Ethiopia; 2020

Background: According to WHO Global report, in low-income countries, more than half of deaths attributable to poor glycemic control are premature. Studies compassed the prevalence of poor self-care practice and glycemic control is by now in the tip of the iceberg above diabetes by becoming a primary offender for fired morbidity and mortality but; they are a neglected tragedy. Currently, diabetes patients are exposed to the intolerable costs of dialysis and organ transplantation because of poor glycemic control and self-care practice induced complications; which in turn increased the beggar population and prevalence of suicidal attempts. Studies underlined optimum self-care practice is needed to avert these complications via adjusting glycemic control status. However, only a minute of relevant studies were conducted in Ethiopia to assess this problem. Therefore, this study was aimed to assess glycemic control and self-care practice among diabetes patients. Objective: The aim of this study was to assess glycemic control and self-care practice among diabetes patients. Methods: Cross-sectional study was conducted among 220 participants selected by systematic sampling technique. The collected data using a structured questionnaire developed for this study from related tools was coded and entered into Epi Data latent version and exported in to SPSS. Logistic regression analysis was carried out to identify independent predictors. Result: Status of self-care practice and glycemic control became good for 24.9% and 23%, respectively. Age, diabetes complications, medication adherence, glucometer, and appointment adherence for glycemic control and; whereas education, diabetes complications, diabetes category, distance, and appointment adherence became independent predictors for self-care practice. Furthermore, the presence of a significant association between glycemic control and self-care practice was assured. Conclusion: Status of good glycemic control and self-care practice were shine red lumps, since it indicates majority of the patients were closed to face premature death and permanent disability. Association between glycemic control and self-care practice, on the other hand, further brightened the need of maximum effort to enhance self-care practice to ease roads to good glycemic control and finally to save diabetes patients from the coming fatal consequences. Responsible bodies have to work hard to raise the coverage of a hospital or to enhance the material capacity of available primary hospitals to enable them to serve diabetes follow-up patients. Health education team has to be formed to provide problem solving-centered education supported by audio visual aids. Funding Statement: Not applicable. Declaration of Interests: No competing interests. Ethics Approval Statement: Ethical approval was obtained from Addis Ababa university Institutional Review Board having protocol number: 037/20/SNM and meeting number: 09/2012EC.

Linear Projection of Estimated Glomerular Filtration Rate Decline with Canagliflozin and Implications for Dialysis Utilization and Cost in Diabetic Nephropathy.

IntroductionDiabetes is a common cause of end-stage kidney disease leading to dialysis or kidney transplantation. Estimated glomerular filtration rate (eGFR) measures kidney function, and differences in the rate (slope) of eGFR decline can be used to assess treatment effects on kidney function over time. In the CREDENCE trial, the sodium glucose co-transporter 2 inhibitor canagliflozin slowed the rate of eGFR decline by 60% compared to placebo in patients with diabetes and chronic kidney disease. This analysis utilized eGFR slopes from CREDENCE to estimate the difference in time to dialysis by treatment arm and estimated the economic value of that delay.MethodsA linear decline in eGFR and maintenance of stable therapy were assumed for the canagliflozin and placebo arms in CREDENCE. Mean eGFR over time was calculated using acute (baseline to week 3) and chronic (week 3 onward) slopes. Reaching eGFR of 10 ml/min/1.73 m2 was assumed to represent the need for chronic dialysis. The difference in time to dialysis between treatments was calculated. Based on the average duration of dialysis, annual dialysis costs were determined, discounting 2020 US dollars at an inflation rate of 4%.ResultsFollowing the acute and chronic eGFR slopes, the projected time to dialysis was 22.85 years for canagliflozin and 9.90 years for placebo. Based on 95% confidence intervals from CREDENCE, the model-estimated difference in time to dialysis was 9.27–17.48 years. With a mean baseline participant age of 63 years, the delay in dialysis with canagliflozin would be associated with a reduction in dialysis costs of approximately $170,000 per patient in 2020 dollars.ConclusionUsing clinical trial data, canagliflozin treatment was projected to delay dialysis by approximately 13 years, which could translate to a substantial cost savings. More precise estimates should be investigated with considerations for nonlinear eGFR slope trajectory, competing risks, and patient characteristics.Trial RegistrationClinicalTrials.gov identifier, NCT02065791.Electronic supplementary materialThe online version of this article (10.1007/s13300-020-00953-4) contains supplementary material, which is available to authorized users.

Financial implications of using extracorporeal membrane oxygenation following heart transplantation

Primary graft dysfunction after heart transplant is associated with high morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) can be used to wean patients from cardiopulmonary bypass. This study retrospectively reviews a single-centre experience of post-transplant ECMO in regard to outcomes and associated costs. Between May 2006 and May 2019, a total of 267 adult heart transplants were performed. We compared donor and recipient variables, ECMO duration and the incidence of renal failure, bleeding, infection and cost analysis between ECMO and non-ECMO groups. ECMO support was required postoperatively to manage primary graft dysfunction in 72 (27%) patients. The mean duration of ECMO support was 6 ± 3.2 days. Mean ischaemic times were similar between the groups. There was a significantly higher proportion of ventricular assist device explant to transplant in the ECMO group versus non-ECMO (38.2% vs 14.1%; P < 0.0001). ECMO patients had a longer duration of stay in the intensive care unit (P < 0.0001) and total hospital stay (P < 0.0001). Greater mortality was observed in the ECMO group (P < 0.0001). The median cost of providing ECMO was £18000 [interquartile range (IQR): £12750-£24000] per patient with an additional median £35225 (IQR: £21487.25-£51780.75) for ITU stay whilst on ECMO. The total median cost per patient inclusive of hospital stay, ECMO and dialysis costs was £65737.50 (IQR: £52566.50-£95221.75) in the non-ECMO group compared to £145415.71 (IQR: £102523.21-£200618.96) per patient in the ECMO group (P < 0.0001). Patients with primary graft dysfunction following heart transplantation who require ECMO are frequently bridged to a recovery; however, the medium and longer-term survival for these patients is poorer than for patients who do not require ECMO.

Quality of life in chronic kidney disease: a community perspective using world health organization quality of life: BREF questionnaire

Background: The quality of life is an important assessment tool in improving the quality of care among chronic kidney diseases (CKD) especially in a palliative care setup. This study attempted to assess the quality of life of chronic kidney disease patients.Methods: This community based cross sectional study was conducted among 140 patients who were registered at palliative clinics in Malappuram District, Kerala using a standard tool for quality of life (QOL) in Malayalam version. Domain scores were analysed across clinic epidemiological factors.Results: Mean age of the study population was 53.99 (14.36%). Majority 73 (52.1%) were educated up to upper primary. The median duration of CKD was 4 years and ranged from 3 months to 22 years. 55.3% were undergoing dialysis 16.3% had renal transplantation. Hypertension was reported by 65% and diabetes by 50.7%. The highest score was obtained in the environmental and lowest in the psychological domain. Age below 40 years, male gender and provision of an income was associated with better QOL scores and perception scores. QOL was significantly higher in all domains among those who had undergone renal transplantation compared to those on hemodialysis. Conclusions: The status of renal transplantation and younger age group positively affected the good quality of life. Considering the cost of renal transplantation and post-transplant survival peritoneal dialysis could be promoted in low resource settings. Secondary prevention of hypertension and diabetes should be addressed at programme level to delay nephropathy.

Kidney health for everyone everywhere - from prevention to detection and equitable access to care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can beimplemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers.

Computational Fluid Dynamics (CFD) Modeling and Simulation of Flow Regulatory Mechanism in Artificial Kidney Using Finite Element Method.

There is an enormous need in the health welfare sector to manufacture inexpensive dialyzer membranes with minimum dialysis duration. In order to optimize the dialysis cost and time, an in-depth analysis of the effect of dialyzer design and process parameters on toxins (ranging from tiny to large size molecules) clearance rate is required. Mathematical analysis and enhanced computational power of computers can translate the transport phenomena occurring inside the dialyzer while minimizing the development cost. In this paper, the steady-state mass transport in blood and dialysate compartment and across the membrane is investigated with convection-diffusion equations and tortuous pore diffusion model (TPDM), respectively. The two-dimensional, axisymmetric CFD model was simulated by using a solver based on the finite element method (COMSOL Multiphysics 5.4). The effect of design and process parameters is analyzed by solving model equations for varying values of design and process parameters. It is found that by introducing tortuosity in the pore diffusion model, the clearance rate of small size molecules increases, but the clearance rate of large size molecules is reduced. When the fiber aspect ratio (db/L) varies from 900 to 2300, the clearance rate increases 37.71% of its initial value. The results also show that when the pore diameter increases from 10 nm to 20 nm, the clearance rate of urea and glucose also increases by 2.09% and 7.93%, respectively, with tolerated transport of albumin molecules.

Evaluating multiple living kidney donor candidates simultaneously is more cost-effective than sequentially

When multiple living donor candidates come forward to donate a kidney to the same recipient, some living donor programs evaluate one candidate at a time to avoid unnecessary evaluations. Evaluating multiple candidates concurrently rather than sequentially may be cost-effective from a societal perspective if it reduces the time recipients spend on dialysis. We used a simple decision tree to estimate the cost-effectiveness of evaluating two to four candidates simultaneously rather than sequentially as potential kidney donors for the same intended recipient. Evaluating two donor candidates simultaneously cost $1,266 (CAD) more than if they were evaluated sequentially, but living donation occurred one month earlier. This translated into $6,931 in averted dialysis costs and a total cost-savings of $5,665 per intended recipient. Simultaneous evaluations also resulted in one percent more living donor transplants and overall gains in quality-of-life as recipients spent less time on dialysis. If recipients were free from dialysis at the start of donor candidate evaluations, simultaneous evaluations also reduced the rate of dialysis initiation by two percent. Benefits were also observed in the three- and four-candidate scenarios. Thus, living donor programs should consider evaluating up to four living donor candidates simultaneously when they come forward for the same recipient as health care system costs incurred are more than offset by avoided dialysis costs.

Ethical challenges in nephrology: a call for action.

The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis ofspecific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.

Health Care Costs by Type of Expenditure across eGFR Stages among Patients with and without Diabetes, Cardiovascular Disease, and Heart Failure.

CKD is associated with higher health care costs that increase with disease progression. However, research is lacking on the type of health care costs associated with CKD across all stages in a general population with a substantial comorbidity burden. Using electronic medical records of an integrated delivery system, we evaluated health care costs by expenditure type in general and in patients with CKD by eGFR and presence of comorbidities. We categorized 146,132 patients with eGFR data in 2016 or 2017 and examined nonmutually exclusive groups according to presence of diabetes mellitus, cardiovascular disease, or heart failure. We used 1 year of follow-up data to calculate outpatient, inpatient, emergency, pharmaceutical, dialysis, and total health care costs by eGFR (Kidney Disease Improving Global Outcomes-defined eGFR categories), adjusted for age, sex, and nonwhite race. Mean total health care costs among patients with CKD without comorbidities were 31% higher than among patients without CKD ($7374 versus $5631, respectively). Hospitalizations accounted for 35% of total costs among those with CKD and no comorbidities but up to 55% among patients with CKD and heart failure. The proportion of costs attributable to hospitalizations accelerated with declining kidney function, reaching as high as 66%. Poorer kidney function and the presence of diabetes mellitus, cardiovascular disease, or heart failure drive substantial health care costs and increase the proportion of costs attributable to inpatient care. The large contribution of inpatient costs begins in earlier stages of CKD and escalates as kidney function declines. Additional therapies to reduce CKD incidence, slow CKD progression, and lower hospitalization risk are needed to benefit patients and reduce CKD's economic burden.