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NDT Advance Access originally published online on April 20, 2006
Nephrology Dialysis Transplantation 2006 21(8):2049-2052; doi:10.1093/ndt/gfl168
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© The Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Editorial Comment

Costs and benefits of improving renal failure treatment—where do we go?

Claude Jacobs

Service de Néphrologie, Hôpital de la Pitié, Paris, France

Correspondence and offprint requests to: Dr C. Jacobs, Service de Néphrologie, Hôpital de la Pitié, 83, Boulevard de l'Hôpital 75013, Paris, France. Email: claude.jacobs{at}psl.aphp.fr; claude.jacobs{at}psl.ap-hop-paris.fr

Keywords: chronic kidney disease; dialysis; economics; nephroprotection

Less than 50 years ago, a therapeutic revolution totally changed the inevitable lethal prognosis of established chronic kidney disease (CKD), as maintenance dialysis methods and renal transplantation (TX) proved the possibility of prolonged survival for patients with end-stage renal failure (ESRF). The first priority of clinical nephrologists in developed countries has, therefore, been the struggle for the widest possible implementation of dialysis and transplant facilities, and the training of medical, nursing and technical staff in these new areas of medical practice. By the end of 2004, close to 1.8 million patients were treated worldwide with renal replacement therapy (RRT), 77% on maintenance dialysis and 23% living with a functional transplant [1]. To date, about 90% of patients benefiting from RRT live in the more developed countries of the Western hemisphere, Japan and Australia, while sadly, more than 5.2 billion people, 82% of the of the total world population, still have no, or only severely rationed, access to these expensive life-saving technologies [1,2]. In recent years, the skyrocketing costs of CKD/end-stage renal disease (ESRD) management in developed countries due to the relentlessly increasing number of incident and prevalent patients requiring RRT has strongly stimulated the clinical applications of the ‘nephroprotection concept’ aimed at the early detection and subsequent prevention of progression of CKD, mainly through lifestyle adjustment and the use of new pharmacological agents [3].

Following this line of thought, the objective assigned to nephroprotection is, from the earliest stage of diagnosed CKD, to retard (or even avoid) progression to ESRF, while providing the patients with the longest survival, lowest morbidity, best social rehabilitation and optimal quality of life, at the lowest cost for health care public or private fund-providers. Meeting this ‘global challenge’ [4] has to take into account the quite frightful forecast of the CKD/ESRF economics, based on the current and future increase of prevalent and incident CKD/ESRD patients. These trends are mainly due to ageing of the general populations in developed countries, which increases the frequency of arterial hypertension and other vascular complications, amongst which renal atherosclerosis, together with the epidemic of type 2 diabetes mellitus [1,2,5–7]. According to the current demographic projections, by the year 2030, there will be about 360 million diabetics worldwide, among whom one in three people might (will?) develop CKD. It is clear that no country and no health care system will be able to offer adequate RRT, and that early detection and prevention are the only means of escape from a scenario of inadequate and unequal distribution of life-saving measures such as RRT [8]. International scientific organizations have thus recently called for action to promote early detection of CKD, primarily in populations at risk (patients with diabetes or hypertension, or those with a history of family renal disease) and implementing on the widest possible scale the currently established prevention strategies aimed at slowing down the progression of CKD; these strategies are listed in Table 1 [9].


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  		Table 1. Recommended measures for nephroprotection

 
All these features play a positive role in the prevention of aggravation of CKD. Modifications of lifestyle, required especially for populations living in Western-style societies, are not limited by financial constraints, but by even more powerful barriers, of a socio-psychological nature. [10]. In fact, control of blood pressure (BP) is the cornerstone of any prevention strategy for reducing cardiovascular and renal morbidity/mortality. A review of nine meta-analyses conducted between 1992 and 2003, among which two included non-diabetic patients [11,12], four included diabetics [13–16] and three included mixed populations [17–19], yielded following conclusions [20]: (i) protective treatment includes angiotensin-converting enzyme inhibitors (ACE-Inhs) or angiotensin receptor antagonists (ARAs) either alone or associated with a diuretic. Target BP is <135/85 mmHg, and even 125/75 mmHg in diabetics. (ii) treatment with ACE-Inhs can significantly reduce the incidence of ESRF in non-diabetic patients with CKD and proteinuria >0.5g/day. The beneficial effect is not related to the levels of BP or renal function at the start of anti-hypertensive treatment [13]. Patients with glomerular and vascular disease achieve better results with anti-hypertensive drugs than those with polycystic kidney disease. In insulin-dependent diabetics, captopril treatment has been found to be associated with a 50% reduction in the combined endpoints of death, dialysis and transplantation, and is significantly more effective than control of BP alone [21]. In non-insulin dependent diabetics, ARAs delay the onset of ESRD in patients with diabetes and nephropathy. Overall, it is estimated that treating 20 patients for 2 years with ARAs may avoid, on average, one case of progression to ESRF [22–24]. It has been calculated that when one takes into consideration all the costs associated with diabetic nephropathy, even expensive renoprotective interventions are cost-effective—provided they are truly effective [25].

Back in 1995, a distinguished American nephrologist sounded an alarm: ‘The world cannot afford uraemia therapy at the start of the 21st Century’ [26]. Ten years later, this statement continues to raise three fundamental questions: (i) is the financial burden of CKD/ESRD therapy still tolerable in the developed countries? (ii) might it become intolerable in the future? and (iii) are there ways and means to reduce, delay or avoid the ‘rising tide’ of patients with ESRD? The responses to these questions will provide a useful working base to design optimally cost-efficient prevention and treatment strategies, particularly for the vast majority of the world population who has no, or only severely restricted, access to modern nephrological care.

In most developed countries, the overall cost of RRT accounts for about 2% of the national health care budgets, which is spent for less than 0.1% of the total population [27]. In the US, the Medicare portion of the ESRD programme grew from $5.8 billion in 1991 to $17 billion by 2002 (6.7% of the whole Medicare budget) and is estimated to increase to more than $28 billion by 2010, with more than 600 000 predicted patients on RRT [6,28]. Facing such tremendous figures, the threat, even in developed countries, of a possible overt or covert ‘rationing’ of RRT fully justifies the search and implementation of the most cost-effective modes of RRT. Top on the list is the long-term successful TX which provides the longest survival and best quality of life for ESRD patients [29]. But for a number of reasons, it is not available for the majority of ESRD patients. Comprehensive retrospective meta-analyses [30], as well as carefully conducted prospective studies on the cost-effectiveness of dialysis methods [31–33], lead to the same conclusion: home dialysis methods [peritoneal dialysis (PD) and home haemodialysis (home HD)] are the most cost-effective methods, followed by satellite HD and, least cost effective, by centre HD. Nevertheless, in 2004, 89% of all dialysis patients worldwide were treated with HD while only 11% with PD. It is thus striking to note that home HD has almost disappeared from the panel of RRT in many countries, while PD is only a very marginal mode of RRT in the wealthiest of countries with the greatest prevalence of patients treated for ESRD (Table 2) [1,6].


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  		Table 2. Distribution of best cost-effective dialysis methods

 
It is beyond any doubt that wider utilization of the more cost-effective modes of RRT would be feasible in many countries. This objective clashes mainly with the lack of motivation of many nephrologists, who either still consider PD as a ‘second class’ RRT, a method which competes with, rather than being complementary to, HD, or ignore it for financial reasons. The reluctance of many ESRD patients to take upon themselves the burden of their treatment is also important. The lack of incentive also comes from the reimbursement policies of RRT by health care administrations of several countries: nephrologists who treat patients with PD instead of centre HD are financially penalized. On the other hand, there are also limitations to the expansion of home dialysis methods, due to the demographic trends of patients with ESRD. Elderly patients, >65/75 years, are the fastest growing segment of the ESRD population. Due to comorbidity or social factors (poor lodging conditions, loneliness), it turns out that a great (and ever greater) proportion of old, and very old, patients are (and must be) treated with centre HD, the most expensive mode of RRT. Because of these factors, it is problematic or even unlikely that substantial reduction of the costs of dialysis treatment will be achieved in the future. This is all the more so, as there is currently no known drug therapy which can reverse advanced CKD. Dialysis is likely to remain the dominant treatment of ESRD for many more years, since the contribution of kidney transplantation will remain limited, mainly due to the shortage of donors and the increase of age and/or comorbidities in ESRD patients. As for ‘futuristic’ modes of therapy, such as xeno-transplantation, stem cell culture and gene therapy, many more years will be needed before their effectiveness is proven and before they make a clinically significant impact.



   Facing such a complex and hazardous future, can the cost-effectiveness of renal therapy be improved? Definitely YES
Top
 Facing such a complex...
References
 
Cost-effective renal care should encompass a global strategy which includes: (i) early detection of CKD in patients at risk, as mentioned earlier; (ii) organization of a sustained medical follow-up of CKD-detected patients aimed at providing all validated measures of optimal nephroprotection; and (iii) of utmost importance is the timely referral to a qualified nephrological team, working in close coordination with the patients’ general practitioner and other required specialists [34,35]. It is worrying to note that because of the delayed referral, the outcome of many ESRF patients is directly threatened and the cost of the early stages of RRT greatly increased, even in countries where access to nephrology facilities is widely available and which offer all therapeutic modalities integrated into a combined dialysis–transplantation programme [36–39]. Early referral to the nephrologist offers an optimal chance of timely initiation of RRT for well-prepared patients and families, the opportunity for choosing the best patient-specific and most cost-effective method of RRT, i.e. TX and/or out-of-centre-dialysis (PD, home HD or satellite HD).

Conflict of interest statement. None declared.



   References
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 Facing such a complex...
 References
 

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Received for publication: 16. 2.06
Accepted in revised form: 15. 3.06


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