Economic impact of extended time on peritoneal dialysis as a result of using polyglucose: the application of a Markov chain model to forecast changes in the development of the ESRD programme over time

Is the cost of the new home dialysis techniques still advantageous compared to in-center hemodialysis? An Italian single center analysis and comparison with experiences from western countries

Introduction

Potential advantages of home dialysis remained a questionable issue. Three main factors have to be considered: the progressive reduction in the cost of consumables for in-Center hemodialysis (IC-HD), the widespread use of incremental Peritoneal Dialysis (PD), and the renewed interest in home hemodialysis (H-HD) in the pandemic era. Registries data on prevalence of dialysis modalities generally report widespread underemployment of home dialysis despite PD and H-HD could potentially provide clinical benefits, improve quality of life, and contrast the diffusion of new infection among immunocompromised patients.

Methods

We examined the economic impact of home dialysis by comparing the direct and indirect costs of PD (53 patients), H-HD (21 patients) and IC-HD (180 patients) in a single hospital of North-west Italy. In order to achieve comparable weekly costs, the average weekly frequency of dialysis sessions based on the dialysis modality was calculated, the cost of individual sessions per patient per week normalized, and the monthly and yearly costs were derived.

Results

As expected, PD resulted the least expensive procedure (€ 23,314.79 per patient per year), but, notably, H-HD has a lower average cost than IC-HD (€ 35,535.00 vs. € 40,798.98). A cost analysis of the different dialysis procedures confirms the lower cost of PD, especially continuous ambulatory PD, compared to any extracorporeal technique.

Discussion

Among the hemodialysis techniques, home bicarbonate HD showed the lowest costs, while the weekly cost of Frequent Home Hemodialysis was found to be comparable to In-Center Bicarbonate Hemodialysis.

Longitudinal Studies 3: Data Modeling Using Standard Regression Models and Extensions

In longitudinal studies, the relationship between exposure and disease can be measured once or multiple times while participants are monitored over time. Traditional regression techniques are used to model outcome data when each epidemiological unit is observed once. These models include generalized linear models for quantitative continuous, discrete, or qualitative outcome responses, and models for time-to-event data. When data come from the same subjects or group of subjects, observations are not independent and the underlying correlation needs to be addressed in the analysis. In these circumstances, extended models are necessary to handle complexities related to clustered data, and repeated measurements of time-varying predictors and/or outcomes.

The osmo-metabolic approach: a novel and tantalizing glucose-sparing strategy in peritoneal dialysis

Peritoneal dialysis (PD) is a viable but under-prescribed treatment for uremic patients. Concerns about its use include the bio-incompatibility of PD fluids, due to their potential for altering the functional and anatomical integrity of the peritoneal membrane. Many of these effects are thought to be due to the high glucose content of these solutions, with attendant issues of products generated during heat treatment of glucose-containing solutions. Moreover, excessive intraperitoneal absorption of glucose from the dialysate has many potential systemic metabolic effects. This article reviews the efforts to develop alternative PD solutions that obviate some of these side effects, through the replacement of part of their glucose content with other osmolytes which are at least as efficient in removing fluids as glucose, but less impactful on patient metabolism. In particular, we will summarize clinical studies on the use of alternative osmotic ingredients that are commercially available (icodextrin and amino acids) and preclinical studies on alternative solutions under development (taurine, polyglycerol, carnitine and xylitol). In addition to the expected benefit of a glucose-sparing approach, we describe an ‘osmo-metabolic’ approach in formulating novel PD solutions, in which there is the possibility of exploiting the pharmaco-metabolic properties of some of the osmolytes to attenuate the systemic side effects due to glucose. This approach has the potential to ameliorate pre-existing co-morbidities, including insulin resistance and type-2 diabetes, which have a high prevalence in the dialysis population, including in PD patients.

PD vs HD in Post-Economic Crisis Greece-Differences in Patient Characteristics and Estimation of Therapy Cost

OBJECTIVE

The aim of this study was to investigate patient characteristics and make an estimation of the cost of peritoneal dialysis (PD) and hemodialysis (HD) to Greek society during the economic crisis.

METHODS

We recorded the characteristics and the total cost of dialysis treatment in 100 patients on PD and 100 on HD. Total costs included dialysis procedure, consumables, drugs, laboratory tests, food, and transportation fees (only HD), covered by patients' insurance. Also included were medical and administrative salaries, purchase and maintenance of equipment and sanitary material, all covered by the state hospital.

RESULTS

The mean patient age was 64.5 ± 16.8 years (PD) and 62.8 ± 15.1 (HD) (p < 0,001). The most common cause of end-stage renal disease (ESRD) was diabetes (32% for PD and 24% for HD patients). A total of 35% of the PD patients were employed vs 4% of the HD patients (p < 0,001). The mean distance from home for PD patients was 41.6 ± 17.3 km, while for HD patients, it was 9.4 ± 1.5 km (p < 0,001). Mean monthly cost for PD and HD treatment per patient was €4,019.20 ± 1,126.30 and €3,254.30 ± 37.50, respectively, both fully covered by patients' insurance. Mean monthly cost for PD or HD dialysis unit maintenance was €11,660.80 and €56,270.50, respectively, also fully covered by the state.

CONCLUSION

There is likely to be a considerable difference in terms of total cost of PD vs HD therapy, owing to the fact that the operational cost of a PD unit appears to be significantly lower than that of a HD unit.

Longitudinal studies 3: Data modeling using standard regression models and extensions

In longitudinal studies the relationship between exposure and disease can be measured once or multiple times while participants are monitored over time. Traditional regression techniques are used to model outcome data when each epidemiological unit is observed once. These models include generalized linear models for quantitative continuous, discrete, or qualitative outcome responses, and models for time-to-event data. When data come from the same subjects or group of subjects, observations are not independent and the underlying correlation needs to be addressed in the analysis. In these circumstances extended models are necessary to handle complexities related to clustered data, and repeated measurements of time-varying predictors and/or outcomes.

Prediction of long-term kidney failure in renal transplant with chronic allograft dysfunction using stage-specific hazard rates

OBJECTIVES

The process of kidney failure in renal transplant recipients with chronic allograft dysfunction is characterized by a progressive decline in glomerular filtration rate over time that it is determined by the 5-stage model. This study used stage-based statistical survival analysis to predict graft survival in renal transplant recipients with chronic allograft dysfunction.

MATERIALS AND METHODS

In a single-center, retrospective study, 214 renal transplant recipients with chronic allograft dysfunction were investigated at a university hospital in Iran from 1997 to 2005. At each patient visit, kidney function was assessed using glomerular filtration rate and stage of disease.

RESULTS

The estimated stage-specific hazard rates of disease progression are stage one, 453.936; stage two, 485.040; stage three, 545.808; and stage four; 649.488 per 1000 person-years. The estimated mean times in each stage were as follows: kidney damage with normal or increased glomerular filtration rate, 26.43 months; kidney damage with mildly decreased glomerular filtration rate, 24.74 months; moderate kidney disease, 21.98 months; and severe kidney disease; 18.48 months. These estimates yield a mean time from stage 1 to kidney failure of 91.63 months. The probability of graft survival was predicted using estimated stage-specific hazard rates. The 18th, 58th, 118th, and 155th months death-censored graft survival probabilities were 0.99, 0.75, 0.25, and 0.10.

CONCLUSIONS

In this method of survival analysis, we can determine a statistical model according to a real clinical model in renal transplant recipients with chronic allograft dysfunction. It enables us to determine the stage-specific hazard rates of disease progression. These findings can help nephrologists to understand the kidney disease process and better predict graft survival.

[Peritoneal dialysis for ESRD patients: financial aspects]

Peritoneal dialysis (PD) is as least as good as hemodialysis (HD) for the treatment of end stage kidney disease, considering morbidity and mortality, and better for quality of life. The best result is obtained when the patient can benefit of the sequential treatment, PD first and then HD if necessary. Furthermore, the cost of a patient treated by PD is less than the cost of the same patient treated by HD, at least in developed countries. But, all around the word, the rate of usage of PD don't grow, or decline. One can expect that, as no medical reason can explain this, the cause is economic. Multiple economics aspects and expenses posts for DP are analyzed, as the results of some financial decisions taken in one country or the other, keeping in mind the French system or reimbursement. We conclude that economic incitations may help for the development of PD, if they don't penalize one of the partners (insurance, clinics, doctors of patients), and if in the same time there is an improvement of the formation and information of doctors and patient.

Reimbursement and economic factors influencing dialysis modality choice around the world

The worldwide incidence of kidney failure is on the rise and treatment is costly; thus, the global burden of illness is growing. Kidney failure patients require either a kidney transplant or dialysis to maintain life. This review focuses on the economics of dialysis. Alternative dialysis modalities are haemodialysis (HD) and peritoneal dialysis (PD). Important economic factors influencing dialysis modality selection include financing, reimbursement and resource availability. In general, where there is little or no facility or physician reimbursement or payment for PD, the share of PD is very low. Regarding resource availability, when centre HD capacity is high, there is an incentive to use that capacity rather than place patients on home dialysis. In certain countries, there is interest in revising the reimbursement structure to favour home-based therapies, including PD and home HD. Modality selection is influenced by employment status, with an association between being employed and PD as the modality choice. Cost drivers differ for PD and HD. PD is driven mainly by variable costs such as solutions and tubing, while HD is driven mainly by fixed costs of facility space and staff. Many cost comparisons of dialysis modalities have been conducted. A key factor to consider in reviewing cost comparisons is the perspective of the analysis because different costs are relevant for different perspectives. In developed countries, HD is generally more expensive than PD to the payer. Additional research is needed in the developing world before conclusive statements may be made regarding the relative costs of HD and PD.