Reducing the costs of chronic kidney disease while delivering quality health care: a call to action

Key Points

  • The treatment of chronic kidney disease (CKD) and of end-stage kidney disease (ESRD) has a high societal cost

  • Insufficient efforts are being made to promote the use of cost-effective renal replacement therapies (RRT), such as transplantation and home dialysis (including peritoneal dialysis)

  • In CKD and in many other chronic diseases, the time has come to decrease investment in curative approaches and to focus on prevention

  • The relative costs and benefits of each approach should be carefully analysed before a preventive or curative method is favoured

  • A need exists for more health-economic studies of primary and secondary prevention in CKD to be conducted, and for the quality of such research to be improved

Abstract

The treatment of chronic kidney disease (CKD) and of end-stage renal disease (ESRD) imposes substantial societal costs. Expenditure is highest for renal replacement therapy (RRT), especially in-hospital haemodialysis. Redirection towards less expensive forms of RRT (peritoneal dialysis, home haemodialysis) or kidney transplantation should decrease financial pressure. However, costs for CKD are not limited to RRT, but also include nonrenal health-care costs, costs not related to health care, and costs for patients with CKD who are not yet receiving RRT. Even if patients with CKD or ESRD could be given the least expensive therapies, costs would decrease only marginally. We therefore propose a consistent and sustainable approach focusing on prevention. Before a preventive strategy is favoured, however, authorities should carefully analyse the cost to benefit ratio of each strategy. Primary prevention of CKD is more important than secondary prevention, as many other related chronic diseases, such as diabetes mellitus, hypertension, cardiovascular disease, liver disease, cancer, and pulmonary disorders could also be prevented. Primary prevention largely consists of lifestyle changes that will reduce global societal costs and, more importantly, result in a healthy, active, and long-lived population. Nephrologists need to collaborate closely with other sectors and governments, to reach these aims.

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Figure 1: The burden of chronic kidney disease (CKD)*.
Figure 2: The network of chronic diseases and their mutual influences.
Figure 3: Societal costs for the care of patients with chronic kidney disease in the UK.
Figure 4: Savings in societal costs through secondary prevention of chronic kidney disease (CKD).

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Acknowledgements

The European Kidney Health Alliance (EKHA) is a strategic alliance of European nonprofit organizations representing all European key stakeholders in kidney health: patients, nephrologists, researchers and allied health workers. Its full members are the European Kidney Patient's Federation (EKPF) (formerly CEAPIR); European Dialysis & Transplant Nurses Association/European Renal Care Association (EDTNA-ERCA); the International Federation of Kidney Foundations (IFKF); and European Renal Association–European Dialysis and Transplant Association (ERA-EDTA). In addition, several European national and other non-profit kidney organizations are Associate Members. EKHA's principal aims are to raise awareness of the importance of kidney health and the growing societal burden of CKD at the European level, and to influence European strategies for early detection and prevention, and for scientific research into chronic kidney disease. The 2016 EKHA Kidney Forum was supported financially by an unrestricted grant from Baxter Health Care, B. Braun, Amgen, Astra-Zeneca and Vifor Fresenius Medical Care Renal Pharma. The remaining activities of EKHA are funded by the member societies. The Management Committee of EKHA is currently composed of: R. Vanholder (chair); N. Lameire (past Chair); M. Murphy, L. Skar (EKPF); M. Eleftheroudi, A. Gorke (EDTNA-ERCA); T. Oostrom, M. Ubbink (IFKF); and A. Wiecek and M. Fontana (ERA-EDTA).

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All authors contributed to researching data for the article, discussing the article's content, and revising or editing the manuscript before submission. R.V. wrote the first draft of the article, and then coordinated subsequent versions with input from the other authors.

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Correspondence to Raymond Vanholder.

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Competing interests

R.V. has received speakers' and consultancy honoraria and travel support from Nikisho, Nipro, Fresenius Medical Care, Bayer and Astra-Zeneca. L.A. has received speakers' and consultancy honoraria from Sanofi, Bayer, Novartis and Astra-Zeneca. E.B. has received speakers' honoraria from Fresenius Medical Care and Baxter Health Care. R.G. is member of steering committees of randomized controlled trials (co)sponsored by Bayer, Genzyme-Sanofi, Ipsen and Otsuka, and has received research grants from these companies as well as from Abbvie, Baxter and the Dutch Kidney Foundation. R.O. has consulted for Astellas, Fresenius Medical Care, TEVA and Pfizer and his unit has received research grants from Astellas, TEVA, Pfizer, Amgen and Novartis. M.J.P. has received grant funding from Sigma Tau, GSK, Boehringer Ingelheim, Pfizer, MundiPharma, GMASOL, Ingress Health, Bayer, Bristol-Myers Squibb, AbbVie, MSD, Sanofi and Astra, and received honoraria from Vertex, Pfizer, Quintiles, Mapi, Astellas, Novartis, OptumInsight, Swedish Orphan, Innoval, Jansen, Sanofi, Intercept, Pharmerit, GSK and MSD, and has stocks in Ingress Health. W.V.B. has received honoraria from Fresenius Medical Care, Gambro and Baxter Healthcare, and is a member of the steering committee of clinical studies sponsored by Fresenius Medical Care and Baxter Healthcare. J.J.G.-Z., N.L., R.L.M, M.T. and C.Z declare no competing interests.

Supplementary information

Supplementary information S1 (table)

Summary of health-economic studies on CKD and conditions leading to CKD (DOC 62 kb)

Supplementary information S2 (box)

Explanation of Quality of Health Economic Studies (QHES) scoring of included models (DOC 31 kb)

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Glossary

Opportunity costs

The health benefits that could have been achieved had the money been spent on the best alternative option.

Benefit

Any intervention for which the results offer added financial or health-related value.

Quality-adjusted life year

(QALY) A life year adjusted for its utility. The plural (QALYs) is a measure of the utility of individual life years lived multiplied by duration (survival).

Discounting

The reduction in the value of a future cost or benefit at a prespecified 'discount rate', which depends on its temporal distance from the starting point.

Cost-effectiveness

An economic evaluation in which the incremental costs of an intervention are compared with the incremental benefits.

Incremental cost-effectiveness ratio

The difference between costs of two interventions divided by the difference in the outcomes.

Direct medical costs

Costs of resources in the health-care sector (for example, drugs).

Indirect medical costs

Medical costs that arise from the life years gained.

Markov model

A decision model that enables transitions between different health states over a period of time (often defined as life long).

Utility

The measure of the preference or value that an individual or society attribute to a health state. This is a quality of life score that ranges from 0 for death to 1 for perfect health, with negative scores being allowed for states considered worse than death.

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Vanholder, R., Annemans, L., Brown, E. et al. Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat Rev Nephrol 13, 393–409 (2017). https://doi.org/10.1038/nrneph.2017.63

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