title: Economics of dialysis dependence following renal replacement therapy for critically ill acute kidney injury patients.
abstract: BACKGROUND
  The obective of this study was to perform a cost-effectiveness analysis comparing intermittent with continuous renal replacement therapy (IRRT versus CRRT) as initial therapy for acute kidney injury (AKI) in the intensive care unit (ICU).
  
  
  METHODS
  Assuming some patients would potentially be eligible for either modality, we modeled life year gained, the quality-adjusted life years (QALYs) and healthcare costs for a cohort of 1000 IRRT patients and a cohort of 1000 CRRT patients. We used a 1-year, 5-year and a lifetime horizon. A Markov model with two health states for AKI survivors was designed: dialysis dependence and dialysis independence. We applied Weibull regression from published estimates to fit survival curves for CRRT and IRRT patients and to fit the proportion of dialysis dependence among CRRT and IRRT survivors. We then applied a risk ratio reported in a large retrospective cohort study to the fitted CRRT estimates in order to determine the proportion of dialysis dependence for IRRT survivors. We conducted sensitivity analyses based on a range of differences for daily implementation cost between CRRT and IRRT (base case: CRRT day $632 more expensive than IRRT day; range from $200 to $1000) and a range of risk ratios for dialysis dependence for CRRT as compared with IRRT (from 0.65 to 0.95; base case: 0.80).
  
  
  RESULTS
  Continuous renal replacement therapy was associated with a marginally greater gain in QALY as compared with IRRT (1.093 versus 1.078). Despite higher upfront costs for CRRT in the ICU ($4046 for CRRT versus $1423 for IRRT in average), the 5-year total cost including the cost of dialysis dependence was lower for CRRT ($37 780 for CRRT versus $39 448 for IRRT on average). The base case incremental cost-effectiveness analysis showed that CRRT dominated IRRT. This dominance was confirmed by extensive sensitivity analysis.
  
  
  CONCLUSIONS
  Initial CRRT is cost-effective compared with initial IRRT by reducing the rate of long-term dialysis dependence among critically ill AKI survivors.
authors.affiliation: Economic Evaluation of Medical Innovation Research Unit, Department of Public Health Sciences, Faculty of Medicine, University of Liège, Liège, Belgium.
authors.forename: Olivier
authors.initials: O
authors.lastname: Ethgen
authors.affiliation: Division of Critical Care Medicine, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.
authors.forename: Antoine G
authors.initials: AG
authors.lastname: Schneider
authors.affiliation: Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
authors.forename: Sean M
authors.initials: SM
authors.lastname: Bagshaw
authors.affiliation: Austin Hospital, Melbourne, Victoria, Australia.
authors.forename: Rinaldo
authors.initials: R
authors.lastname: Bellomo
authors.affiliation: Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: John A
authors.initials: JA
authors.lastname: Kellum
mesh_terms: D058186:Acute Kidney Injury / Q000191:economics* / Q000401:mortality / Q000628:therapy; D003362:Cost-Benefit Analysis; D016638:Critical Illness; D003657:Decision Making; D006801:Humans; D007362:Intensive Care Units; D010043:Outcome and Process Assessment, Health Care; D019057:Quality-Adjusted Life Years; D012372:ROC Curve; D006435:Renal Dialysis / Q000191:economics*; D017582:Renal Replacement Therapy / Q000191:economics*; D012189:Retrospective Studies; D015996:Survival Rate
keywords: acute kidney injury; dialysis dependence; economic analysis