[Cost-effectiveness of interventions for end-stage renal disease]

Capacity for the management of kidney failure in the International Society of Nephrology Latin America region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

Successful management of chronic kidney disease (CKD) in Latin America (LA) continues to represent a challenge due to high disease burden and geographic disparities and difficulties in terms of capacity, accessibility, equity, and quality of kidney failure care. Although LA has experienced significant social and economic progress over the past decades, there are still important inequities in health care access. Through this third iteration of the International Society of Nephrology Global Kidney Health Atlas, the indicators regarding kidney failure care in LA are updated. Survey responses were received from 22 of 31 (71%) countries in LA representing 96.5% of its total population. Median CKD prevalence was 10.2% (interquartile range: 8.4%-12.3%), median CKD disability-adjusted life year was 753.4 days (interquartile range: 581.3-1072.5 days), and median CKD mortality was 5.5% (interquartile range: 3.2%-6.3%). Regarding dialysis modality, hemodialysis continued to be the most used therapy, whereas peritoneal dialysis reached a plateau and kidney transplantation increased steadily over the past 10 years. In 20 (91%) countries, >50% of people with kidney failure could access dialysis, and in only 2 (9%) countries, people who had access to dialysis could initiate dialysis with peritoneal dialysis. A mix of public and private systems collectively funded most aspects of kidney replacement therapy (dialysis and transplantation) with many people incurring up to 50% of out-of-pocket costs. Few LA countries had CKD/kidney replacement therapy registries, and almost no acute kidney injury registries were reported. There was large variability in the nature and extent of kidney failure care in LA mainly related to countries' funding structures and limited surveillance and management initiatives.

[Comparative economic evaluation of renal replacement therapies in Argentina, Costa Rica, and UruguayAvaliação econômica comparativa de terapias de substituição renal na Argentina, na Costa Rica e no Uruguai]

Objetivo.

Evaluar las diferencias de costos y prevalencia de las terapias de remplazo renal (TRR) como el trasplante, la diálisis peritoneal y la hemodiálisis en Argentina, Costa Rica y Uruguay, mediante estrategias costo-efectivas de difusión.

Métodos.

Costos y prevalencia de principales financiadores y prestadores por país, y análisis de costo-efectividad mediante modelo de Markov a 5 años, evaluando estrategias de asignación de recursos expresadas por razón incremental de costo-efectividad en costo por año de vida ajustado por calidad.

Resultados.

Se observa dispersión entre los países en el acceso y los valores prestacionales de TRR, que afectan su prevalencia y el punto de equilibrio monetario. Desde el punto de vista de los costos, es más eficiente promover la realización de trasplantes y de diálisis peritoneal, y desalentar la indicación de hemodiálisis, aunque la disponibilidad de cada TRR por país requirió evaluaciones particulares.

Conclusiones.

Promover la realización de trasplantes ahorra costos, aunque los puntos de equilibrio variables requieren determinar diferentes umbrales de costo-efectividad por país. En Argentina y Uruguay, la administración de TRR mejoraría su eficiencia si se aumentan la cantidad de pacientes en diálisis peritoneal y las tasas de donación para trasplantes. En Costa Rica (donde hay tasas elevadas de trasplantes y margen presupuestario), la incorporación de técnicas dialíticas se ajusta por demanda e incidencia de pacientes con ERCT.

Barriers and Facilitators in Timely Detection of Chronic Kidney Disease: Evidences for Decision-Makers

Chronic Kidney Disease (CKD) is classified, according to the glomerular filtratation rate. Timely diagnosis during the first three stages represents a lower expenditure for health systems in the treatment of this disease. Thus, this study intends to identify barriers and facilitators in timely detection of CKD, from the perspective of healthcare providers. This is an exploratory study of the qualitative type. A mapping of the literature was carried out in order to develop the following topics: perceptions of the implications of CKD for the health system at an international level and in Mexico, as well as experience related to barriers and facilitators in timely CKD detection in Mexico. Based on the identified topics, semi-structured interviews were carried out with decision-makers, operational personnel, civil and academic associations representatives in Mexico City and Cuernavaca, Morelos. The main identified barriers were: system fragmentation; overload of services at first and second levels of care; insufficient human resources; lack of updating of the clinical practice guide and scarce training. With respect to facilitators, we found there are civil society actions. Finally, requirements for timely detection of CKD are consistent with what is described in the international guides. The identification of barriers and facilitators in timely CKD detection gives us an outlook of the problem in Mexico and leads to proposals for action. The development of a national program with a strategy for timely detection of CKD may help unify inter-institutional criteria considering the protocols for clinical practice that take into account each institution's organization and resources.

Cost/Utility Study of Peritoneal Dialysis and Hemodialysis in Chile

In Chile the reimbursement/patient/year for chronic peritoneal dialysis (PD) is US$14,654 and for chronic hemodialysis (HD) US$10,909. However, no study comparing global (direct plus indirect) costs has been performed in our country. Our research objective was to compare global costs and quality of life between the two therapies.

Patients ( n = 159) from five selected dialysis units in Chile [57 patients on PD (50 on automated PD) and 102 on standard HD (3 x 4 hours weekly)] were retrospectively studied. No patient had previously received the alternate therapy. Items analyzed were quality of life, customer satisfaction, direct and indirect costs, annual global costs, and cost/utility index. Mean age on HD was 54.14 ± 16.01 years and on PD 49.76 ± 18.88 years ( p > 0.05). No differences in the distribution of diabetic patients between the therapies were found. Hemodialysis and PD groups did not have differences in the quality of life index, although there was better customer satisfaction with PD than with HD. Direct and indirect costs were calculated. We found significant differences in favor of PD in erythropoietin consumption (2.24 ± 1.57 vials/week on HD and 1.35 ± 0.85 vials/week on PD, p < 0.05) and working time (31.0 ± 13.3 hours/week on HD and 38.5 ± 12.2 hours/week on PD, p < 0.05). The quality life index (Health-Related SF-36 Health Survey) was 65.75 on HD and 66.88 on PD. Annual global costs were US$20,803 for HD and US$20,742 for PD. The cost/utility index was 3.16 for HD and 3.10 for PD. Patients on PD have an advantage related to erythropoietin consumption and working capacity compared with HD patients. Addition of related indirect costs to reimbursements gives a more accurate insight into treatment costs. Considering all these parameters, we did not find significant differences between HD and PD in quality life index, cost/utility index, or annual global cost in this Chilean end-stage renal disease population.

Chronic Kidney Disease and Dialysis in Mexico

The increasing rates in incidence and prevalence of chronic kidney disease (CKD) are important challenges for health systems around the world, and are even more significant for undeveloped countries. In Mexico the prevalence of CKD seems to be similar to that in highly developed nations, with diabetes as the leading cause of CKD; however, human and economic resources seem to be insufficient for treatment needs. This is reflected in the unacceptably high mortality rates and in noncompliance with established standards and guidelines. Several measures need to be taken to improve this picture, such as more efficient programs for the prevention of obesity, diabetes, and hypertension. Organizing a national registry of patients with CKD is now a pressing need, as is a continuous search for additional funding and budgets to increase the number of qualified nephrologists and specialized nurses and to continue the much-needed research on CKD.

Uma comparação dos custos do transplante renal em relação às diálises no Brasil

Resumo: O objetivo do presente estudo foi comparar os custos médicos diretos do transplante renal e das terapias renais substitutivas, especificamente a hemodiálise e a diálise peritoneal, sob a perspectiva do Sistema Único de Saúde (SUS). Os custos das terapias renais substitutivas foram extraídos de informações publicadas na literatura. Os itens de custo previstos do transplante renal foram identificados em um hospital privado mediante coleta dos códigos dos procedimentos utilizados para a cobrança do SUS e os demais itens extraídos da literatura. O resultado desta pesquisa indica que, no período dos quatro anos coberto por este estudo, o transplante renal de doador falecido gera uma economia, por paciente, de R$ 37 mil e R$ 74 mil em relação à hemodiálise e à diálise peritoneal, respectivamente. Quanto ao transplante renal de doador vivo, as economias são ainda maiores: R$ 46 mil e R$ 82 mil em relação à hemodiálise e à diálise peritoneal, respectivamente. Este resultado, aliado a análises de sobrevida e qualidade de vida, pode caracterizar o transplante renal como a melhor alternativa do ponto de vista financeiro e clínico, auxiliando na formulação de políticas públicas relacionadas com os transplantes de órgãos no Brasil.

Institutional and familial cost of patients in continuous ambulatory peritoneal dialysis

Objective: to determine the cost of institutional and familial care for patients with chronic kidney disease replacement therapy with continuous ambulatory peritoneal dialysis. Methods: a study of the cost of care for patients with chronic kidney disease treated with continuous ambulatory peritoneal dialysis was undertaken. The sample size (151) was calculated with the formula of the averages for an infinite population. The institutional cost included the cost of outpatient consultation, emergencies, hospitalization, ambulance, pharmacy, medication, laboratory, x-rays and application of erythropoietin. The family cost included transportation cost for services, cost of food during care, as well as the cost of medication and treatment materials acquired by the family for home care. The analysis included averages, percentages and confidence intervals. Results: the average annual institutional cost is US$ 11,004.3. The average annual family cost is US$ 2,831.04. The average annual cost of patient care in continuous ambulatory peritoneal dialysis including institutional and family cost is US$ 13,835.35. Conclusion: the cost of chronic kidney disease requires a large amount of economic resources, and is becoming a serious problem for health services and families. It's also true that the form of patient management in continuous ambulatory peritoneal dialysis is the most efficient in the use of institutional resources and family.

Prevention of gram-positive infections in peritoneal dialysis patients in Hong Kong: a cost-effectiveness analysis

BACKGROUND

Gram-positive bacteria are the major causative pathogens of peritonitis and exit site infection in patients undergoing peritoneal dialysis (PD). We investigated the cost-effectiveness of regular application of mupirocin at the exit site in PD recipients from the perspective of health care providers in Hong Kong.

METHODS

A decision tree was designed to simulate outcomes of incident PD patients with and without regular application of mupirocin over a 1-year period. Outcome measures included total direct medical costs, quality-adjusted life-years (QALYs) gained, and gram-positive infection-related mortality rate. Model inputs were derived from the literature. Sensitivity analyses evaluated the impact of uncertainty in all model variables.

RESULTS

In a base case analysis, the mupirocin group had a higher expected QALY value (0.6496 vs 0.6456), a lower infection-related mortality rate (0.18% vs 1.64%), and a lower total cost per patient (US $258 vs $1661) compared with the control group. The rate of gram-positive peritonitis without mupirocin and the risk of gram-positive peritonitis with mupirocin were influential factors. In 10,000 Monte Carlo simulations, the mupirocin group had significantly lower associated costs, higher QALYs, and a lower mortality rate 99.9% of the time.

CONCLUSIONS

Topical mupirocin appears to be a cost-effective preventive measure against gram-positive infection in incident patients undergoing PD. The cost-effectiveness of mupirocin is affected by the level of infection risk reduction and subject to resistance against mupirocin.

Comparison of cost-utility between automated peritoneal dialysis and continuous ambulatory peritoneal dialysis

BACKGROUND AND AIMS

The use of automated peritoneal dialysis (APD) is increasing compared to continuous ambulatory peritoneal dialysis (CAPD). Surprisingly, little data about health benefits and cost of APD exist, and virtually no information comparing the cost-utility between CAPD and APD is available. We undertook this study to evaluate and compare the health-related quality of life (HRQOL) and cost-utility indexes in patients on CAPD vs.

APD METHODS

This was a prospective cohort of patients initiating dialysis (2008-2009). Two questionnaires were self-administered: European Research Questionnaire Quality of Life (EQ-5D) and Kidney Disease Quality of Life (short form, KDQOL-SF, Rand, Santa Monica, CA). Direct medical costs (DMC) were determined from the health provider perspective including the following medical resource utilization: outpatient clinic/emergency care, dialysis procedures, medications, laboratory tests, hospitalization, and surgery. Cost-utility indexes were calculated dividing total mean cost by indicators of the HRQOL.

RESULTS

One hundred twenty-three patients were evaluated: 77 on CAPD and 46 on APD. Results of the EQ-5D and KDQOL-SF questionnaires were significantly better in APD compared to the CAPD group. Main costs in both APD and CAPD were attributed to hospitalization and dialysis procedures followed by medication and surgery. Outpatient clinic visits and laboratory tests were significantly more costly in CAPD than in APD, whereas dialysis procedures were more expensive in the latter. Cost-utility indexes were significantly better in APD compared to CAPD.

CONCLUSIONS

A significant cost-utility advantage of APD vs. CAPD was observed. The annual DMC per-patient were not different between groups but the HRQOL was better in the APD compared to the CAPD group.

Cost Utility of Sirolimus versus Tacrolimus for the Primary Prevention of Graft Rejection in Renal Transplant Recipients in Mexico

OBJECTIVE

Therapies for end-stage renal disease improve quality of life, and survival. In Mexico, clinicians often must choose between different therapies without the availability of comparative outcomes evaluation. The present study evaluates the comparative cost-utility of sirolimus (SIR) versus tacrolimus (TAC) for the primary prevention of graft rejection in renal transplant recipients in Mexico.

METHODS

We used modeling techniques to estimate the cost-effectiveness of SIR versus TAC to prevent graft rejection in patients with end-stage renal disease in the Mexican setting. The model estimates the cost of quality-adjusted life-year (QALY) per patient. We applied a 20-year horizon (1-year Markov cycles). Cost-effectiveness was expressed in terms of cost per QALY. All costs are presented in 2011 US dollars. Probabilistic sensitivity analyses were conducted.

RESULTS

The total cost for the SIR treatment arm over the 20-year duration of the model is estimated to be $136,778. This compares with $142,624 for the TAC treatment arm, resulting in an incremental cost of SIR compared with that of TAC of-$5,846. Over 20 years, SIR was estimated to have 8.18 QALYs compared with 7.33 QALYs for TAC. The resulting incremental utility of SIR compared with that of TAC is 0.84 QALY gained. SIR is estimated to be both less costly and more effective than TAC, indicating that it is the dominant strategy. Notably, results suggest that SIR has a 78% probability of being dominant over the TAC strategy and a 100% probability of having an incremental cost-effectiveness ratio at or below $10,064 (1 GDP) per QALY.

CONCLUSIONS

These analyses suggest that in the Mexican setting, the use of SIR in place of TAC for the prevention of graft rejection in this population is likely to be cost saving.

Economic Burden of Incident Unplanned Starts on Peritoneal Dialysis in a High Specialty Health Care Facility in Mexico City

OBJECTIVES

Few studies have examined hospitalization costs for unplanned initiation of peritoneal dialysis (PD). We used data from a health care facility in Mexico to examine first hospitalization costs associated with the unplanned initiation of PD.

METHODS

Descriptive analyses focusing on initial hospitalization costs during the unplanned initiation of PD were conducted. In addition, multivariate regression models examined the association of costs with requiring urgent hemodialysis (HD) at the time of starting PD, and the association of driving distance with requiring urgent HD.

RESULTS

Of 195 patients hospitalized in 2010 for PD catheter placement, 51 patients met criteria for unplanned PD initiation and 25 of them required urgent HD prior to PD initiation. Ninety-two percent of the patients received 90% or greater government subsidy of hospital costs. Average inpatient costs for the first hospitalization related to the unplanned initiation of PD were 64,174 Mexican Pesos (MXN) (US $4,657). Costs were 78,683 MXN ($5,710) per patient for those requiring urgent HD and 50,225 MXN ($3,645) for those who did not, a difference (P<0.05) of roughly 28,000 MXN ($2,032), and regression results were similar. In addition, long driving distance to the institution was significantly associated with requiring urgent HD.

CONCLUSIONS

Our findings highlight potential cost savings to payers for developing better strategies to manage PD starts in Mexico and should help inform policy regarding oversight and coverage of low-income patients at risk of dialysis.

Barriers to generalizability of health economic evaluations in Latin America and the Caribbean region

Use and acceptance of health economic evaluations (HEEs) has been much greater in developed than in developing nations. Nevertheless, while developing countries lag behind in the development of HEE methods, they could benefit from the progress made in other countries and concentrate on ways in which existing methods can be used or would need to be modified to fulfill their specific needs. HEEs, as context-specific tools, are not easily generalizable from setting to setting. Existing studies regarding generalizability and transferability of HEEs have primarily been conducted in developed countries. Therefore, a legitimate question for policy makers in Latin America and the Caribbean region (LAC) is to what extent HEEs conducted in industrialized economies and in LAC are generalizable to LAC (trans-regional) and to other LAC countries (intra-regional), respectively. We conducted a systematic review, searching the NHS Economic Evaluation Database (NHS EED), Office of Health Economics Health Economic Evaluation Database (HEED), LILACS (Latin America health bibliographic database) and NEVALAT (Latin American Network on HEE) to identify HEEs published between 1980 and 2004. We included individual patient- and model-based HEEs (cost-effectiveness, cost-utility, cost-benefit and cost-consequences analyses) that involved at least one LAC country. Data were extracted by three independent reviewers using a checklist validated by regional and international experts. From 521 studies retrieved, 72 were full HEEs (39% randomized controlled trials [RCTs], 32% models, 17% non-randomized studies and 12% mixed trial-modeling approach). Over one-third of identified studies did not specifically report the type of HEE. Cost-effectiveness and cost-consequence analyses accounted for almost 80% of the studies. The three Latin American countries with the highest participation in HEE studies were Brazil, Argentina and Mexico. While we found relatively good standards of reporting the study's question, population, interventions, comparators and conclusions, the overall reporting was poor, and evidence of unfamiliarity with international guidelines was evident (i.e. absence of incremental analysis, of discounting long-term costs and effects). Analysis or description of place-to-place variability was infrequent. Of the 49 trial-based analyses, 43% were single centre, 33% multinational and 18% multicentre national. Main reporting problems included issues related to sample representativeness, data collection and data analysis. Of the 32 model-based studies (most commonly using epidemiological models), main problems included the inadequacy of search strategy, range selection for sensitivity analysis and theoretical justifications. There are a number of issues associated with the reporting and methodology used in multinational and local HEE studies relevant for LAC that preclude the assessment of their generalizability and potential transferability. Although the quality of reporting and methodology used in model-based HEEs was somewhat higher than those from trial-based HEEs, economic evaluation methodology was usually weak and less developed than the analysis of clinical data. Improving these aspects in LAC HEE studies is paramount to maximizing their potential benefits such as increasing the generalizability/transferability of their results.

Economic evaluations of dialysis treatment modalities

OBJECTIVES

The purpose of this paper is to review published economic evaluations of dialysis treatment modalities, including hemodialysis (HD) and peritoneal dialysis (PD).

METHODS

A systematic literature review was conducted in both PubMed and EMBASE for the years 1996-2006. Articles were included if they were original research articles comparing PD and HD or comparing subtypes of PD and HD.

RESULTS

Twenty-five articles were included in the formal literature review. The majority of articles were cost evaluations, rather than full economic evaluations of both costs and outcomes. The results show that, in developed nations, HD is generally more expensive than PD to the payer. In developing and emerging economies, mainly due to inexpensive labor and high imported equipment and solution costs, PD is not infrequently perceived to be more expensive than HD. However, the costs of dialysis differ by region and additional research is needed particularly in developing economies.

CONCLUSIONS

HD is a more expensive dialysis modality in developed regions of the world. Research in the developing world is too limited to draw definitive conclusions.

Cost-effectiveness of quadrivalent human papillomavirus (HPV) vaccination in Mexico: a transmission dynamic model-based evaluation

We examined the potential health outcomes and cost-effectiveness of quadrivalent human papillomavirus (HPV) 6/11/16/18 vaccination strategies in the Mexican population using a multi-HPV type dynamic transmission model. Assuming similar cervical screening practices, with or without vaccination, we examined the incremental cost-effectiveness of vaccination strategies for 12 year-old females, with or without male vaccination, and temporary age 12-24 catch-up vaccination for females or both sexes. The most effective strategy therein was vaccination of 12-year-olds, plus a temporary 12-24-year-old catch-up program covering both sexes; whereby HPV 6/11/16/18-related cervical cancer, high-grade cervical precancer, and genital wart incidence was reduced by 84-98% during year 50 following vaccine introduction. Incremental cost-effectiveness ratios in the primary analyses ranged from approximately 3000 dollars (U.S.) per quality-adjusted life year (QALY) gained for female vaccination strategies to approximately 16000 dollars /QALY for adding male vaccination with catch-up.

Kidney transplantion improves the muldimensional quality of life

INTRODUCTION

Quality of life is affected during any illness, especially chronic diseases, such as renal failure.

OBJECTIVE

To evaluate the quality of life after kidney transplantation.

METHODS

One hundred patients were interviewed (60 men, 40 women, mean age 36 +/- 10.4 years, median 35 years) from July to October 2000 using the multidimensional questionnaire WHOQL-Bref.

RESULTS

Eighty-eight percent of patients were satisfied/very satisfied with their general health condition. Seventy-seven percent manifested a good capacity to carry out daily activities, and 75% considered themselves satisfied with their work capacity. Quality of life was considered "very good" or "good" among 80%, and "neither good nor bad" in 20%. None considered quality of life in general as "bad" or "very bad." Most (87%) were satisfied with their current condition and with themselves after the kidney transplant.

CONCLUSION

Patients perceive kidney transplant as capable of improving their quality of life. The most important finding in this study is that the results of the physical and psychological domains did not show any significant difference. It was possible to conclude that the quality of life for most subjects is related to reduction or disappearance of the symptoms caused by the previous disease.

Comparação das informações sobre as prevalências de doenças crônicas obtidas pelo suplemento saúde da PNAD/98 e as estimadas pelo estudo Carga de Doença no Brasil

Neste estudo, estimativas de prevalência de cinco doenças crônicas cirrose, depressão, diabetes, insuficiência renal crônica e tuberculose obtidas pelo Suplemento Saúde da PNAD/98 foram comparadas com as obtidas no Projeto Carga Global de Doença no Brasil. Essas estimativas foram baseadas em análise sistemática de literatura e banco de dados de morbidade disponíveis. Os resultados mostram que a PNAD apresentou número de casos mais elevados para depressão e insuficiência renal crônica, enquanto as estimativas do Projeto Carga de Doença no Brasil apresentou maiores prevalências para cirrose, diabetes e tuberculose.

Long-term (> or =20 yr) status of 14 cadaveric kidney-transplant recipients

The aim of this study was to analyze the status of patients with a successful long-term (> or =20 yr) kidney graft. Nineteen (8.1%) of the 234 recipients who received a cadaveric kidney transplant between 1968 and 1978 in our center are still alive 21.7+/-1.6 yr (mean+/-standard error of the mean) later with a functioning allograft. Function, including measurement of the renal functional reserve (RFR), histological status, and morbidity were evaluated. Fourteen patients agreed to participate in this study. Their current immunosuppressive regimens combined prednisone (P)+azathioprine (AZA) (n=9), P+AZA+cyclosporine (CsA) (n=3) or P+CsA (n=2). Although they described their quality of life as good, 10 patients had mild hypertension, 5 developed 10 malignancies (9 cutaneous), 5 had replicative hepatitis, 8 had osteopenia, and 6 had cataracts, but none had diabetes mellitus. Proteinuria was detected in 6 patients, but was always less than 1 g/d. Mean serum creatinine was 1.28+/-0.28 mg/dL and glomerular filtration rate was 54.5+/-5.3 mL/min/1.73 m2. RFR was present for 4 patients with a mean value of +14.8+/-1.9 mL/min. Their functional status was not correlated with the histological lesions observed in concomitant transplant biopsies. Kidney grafts are able to function well even more than 20 yr post-transplantation, with some having a RFR whose significance remains unknown. Morbidity is of minor clinical severity, but could be further reduced with optimized management. Moreover, transplantation is much less costly than hemodialysis.

[Cost-effectiveness of interventions for end-stage renal disease]

OBJECTIVE

The study reports the cost-effectiveness results of end-stage renal disease (ESDR) patients in Mexico in terms of years of life gained and quality of life and the economic cost with regards to three treatment alternatives that could be considered mutually exclusive: continuous peritoneal ambulatory dialysis (CAPD), hemodialysis (HD) and renal transplant (RT).

METHOD

The economic costs were calculated by using the average cost case-management methodology and further, the probable of life expectancy and the quality of life were cross-sectionally assessed by means of the Quality Adjusted Life Years (QALY) measured by the Rosser Index.

RESULTS

The results show that economic costs in US$ of the three treatment alternatives were: CAPD $5,643.07, HD $9,631.60, and RT $3,021.63. The probability of life expectancy for CAPD and RT for the first and third year were: 86.2% and 66.9%, and 89.9% and 79.6%, respectively. The QALY scores for patients were: CAPD 0.8794, HD 0.8640, and RT 0.9783.

CONCLUSION

The intervention with the highest cost-effectiveness coefficient was the renal transplant (3,088.69), followed by the CAPD (6,416.95) and HD (11,147.68). A significant difference was found between the transplanted patients and patients undergoing dialysis. Finally, this study concluded that the RT offers the least expensive alternative and the greatest number of years of life gained as well as providing significant changes in the quality of life of ESRD patients.