Paying for Frequent Dialysis

Hidden Costs Associated with Conversion from Peritoneal Dialysis to Hemodialysis

Background

Increasing use of peritoneal dialysis (PD) will likely lead to increasing numbers of patients transitioning from PD to hemodialysis (HD). We describe the characteristics of patients who discontinued PD and converted to HD, trajectories of acute-care encounter rates and the total cost of care both before and after PD discontinuation, and the incidence of modality-related outcomes after PD discontinuation.

Methods

We analyzed data in the United States Renal Data System to identify patients aged ≥12 years who were newly diagnosed with ESKD in 2001-2017, initiated PD during the first year of ESKD, and discontinued PD in 2009-2018. We estimated monthly rates of hospital admissions, observation stays, emergency department encounters, and Medicare Parts A and B costs during the 12 months before and after conversion from PD to HD, and the incidence of home HD initiation, death, and kidney transplantation after conversion to in-facility HD.

Results

Among 232,699 patients who initiated PD, there were 124,213 patients who discontinued PD. Among them, 68,743 (55%) converted to HD. In this subgroup, monthly rates of acute-care encounters and total costs of care to Medicare sharply increased during the 6 months preceding PD discontinuation, peaking at 96.2 acute-care encounters per 100 patient-months and $20,701 per patient in the last month of PD. After conversion, rates decreased, but remained higher than before conversion. Among patients who converted to in-facility HD, the cumulative incidence of home HD initiation, death, and kidney transplantation at 24 months was 3%, 25%, and 7%, respectively.

Conclusions

The transition from PD to HD is characterized by high rates of acute-care encounters and health-care expenditures. Quality improvement efforts should be aimed at improving transitions and encouraging both home HD and kidney transplantation after PD discontinuation.

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.

Effects of Keluoxin capsule combined with losartan potassium on diabetic kidney disease: study protocol for a randomized double-blind placebo-controlled multicenter clinical trial

Background

Diabetic kidney disease (DKD) is one of the most important microvascular complications of diabetes, and its prevalence has increased dramatically in the past few decades. DKD is responsible for considerable morbidity and mortality of patients with diabetes. Keluoxin capsule (KLX) is a Chinese patent medicine that has been used in the clinic to control DKD for years. Previous studies have shown that KLX appears to reduce proteinuria, but the study protocols as well as the primary outcome need to be improved. Thus, we aim to evaluate whether losartan potassium combined with KLX is more effective than losartan potassium in DKD treatment and to provide validated evidence for the application of KLX in the treatment of DKD.

Methods

We will conduct a randomized double-blind placebo-controlled multicenter clinical trial. A total of 252 participants diagnosed with DKD recruited from 18 institutions will be randomly allocated to either a losartan potassium plus KLX (n = 126) or a losartan potassium plus placebo group (n = 126). The participants will be administered KLX or placebo in addition to losartan potassium for 24 weeks. The primary outcome measure will be the decline in estimated glomerular filtration rate (eGFR) (ml/min/1.73 m²/year) from baseline within 24 weeks, and the secondary outcomes will be the incidence of serum creatinine doubling, the incidence of end-stage renal disease (ESRD), the proportion of subjects with a progressive decline in eGFR > 30%, the percent change in 24 h urinary total protein (UTP), the change in the urinary albumin/creatinine ratio (UACR), and the total effective rate of the traditional Chinese medicine (TCM) syndrome scale scores. Comparison of the differences in the variables between groups will be performed according to the data revealed by independent t tests, chi-squared tests, Fisher’s exact tests, or Wilcoxon’s tests. All statistical tests will be two-sided, and significance will be considered for p values < 0.05.

Discussion

This study will be the first randomized clinical trial to evaluate the efficacy and safety of KLX versus the placebo for the treatment of patients with DKD. The outcome of this trial will provide a basis for prescribing KLX to patients with DKD.

Trial registration

Chinese Clinical Trial Registry (www.chictr.org.cn) ChiCTR1900021113. Registered on January 29, 2019.