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American Journal of Kidney Diseases

Cost-Effectiveness of Initiating Dialysis Early: A Randomized Controlled Trial

Published:February 24, 2011DOI:https://doi.org/10.1053/j.ajkd.2010.12.018

      Background

      Planned early initiation of dialysis therapy based on estimated kidney function does not influence mortality and major comorbid conditions, but amelioration of symptoms may improve quality of life and decrease costs.

      Study Design

      Patients with progressive chronic kidney disease and a Cockcroft-Gault estimated glomerular filtration rate of 10-15 mL/min/1.73 m2 were randomly assigned to start dialysis therapy at a glomerular filtration rate of either 10-14 (early start) or 5-7 mL/min/1.73 m2 (late start).

      Setting & Population

      Of the original 828 patients in the IDEAL (Initiation of Dialysis Early or Late) Trial in renal units in Australia and New Zealand, 642 agreed to participate in this cost-effectiveness study.

      Study Perspective & Timeframe

      A societal perspective was taken for costs. Patients were enrolled between July 1, 2000, and November 14, 2008, and followed up until November 14, 2009.

      Intervention

      Planned earlier start of maintenance dialysis therapy.

      Outcomes

      Difference in quality of life and costs.

      Results

      Median follow-up of patients (307 early start, 335 late start) was 4.15 years, with a 6-month difference in median duration of dialysis therapy. Mean direct dialysis costs were significantly higher in the early-start group ($10,777; 95% CI, $313 to $22,801). Total costs, including costs for resources used to manage adverse events, were higher in the early-start group ($18,715; 95% CI, −$3,162 to $43,021), although not statistically different. Adjusted for differences in baseline quality of life, the difference in quality-adjusted survival between groups over the time horizon of the trial was not statistically different (0.02 full health equivalent years; 95% CI, −0.09 to 0.14).

      Limitations

      Missing quality-of-life questionnaires and skewed cost data, although similar in each group, decrease the precision of results.

      Conclusion

      Planned early initiation of dialysis therapy in patients with progressive chronic kidney disease has higher dialysis costs and is not associated with improved quality of life.

      Index Words

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      Linked Article

      • Regarding Early Initiation of Dialysis
        American Journal of Kidney DiseasesVol. 58Issue 3
        • Preview
          In the article by Harris et al1 and the accompanying editorial by Manns and Quinn,2 there is no mention of the financial motivation to start dialysis therapy early. In the United States, partial ownership of dialysis centers through joint ventures is common. There is a distinct financial benefit to “keep the center full” and place patients on dialysis therapy irrespective of what is in the patient's best interests. In addition to the ownership issue, having a large number of dialysis patients increases the income of the nephrologist.
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