Search

Background and Aims Chronic kidney disease (CKD) is a debilitating and costly condition, with an estimated global prevalence of approximately 10%. Progression of CKD is associated with end-stage renal disease, cardiovascular events and premature mortality, as well as increased requirement for renal replacement therapies (RRTs), which are associated with significant healthcare costs and resource use. Furthermore, patients with CKD often have additional comorbidities, which are associated with CKD progression and increased costs. The trajectories of CKD prevalence, progression, outcomes and the related costs are therefore critical considerations for public health and policy planning. Using country-specific, patient-level microsimulation, Inside CKD aims to model the global clinical and economic burden of CKD from 2020 to 2025. Method We used the Inside CKD microsimulation to model the economic burden of CKD in the Americas and Asia-Pacific region. We developed a virtual general population for each country using national survey data and relevant data from published literature. Data inputs included country demographics, the prevalence of CKD and RRT, comorbidities and complication rates as well as associated healthcare costs. CKD stages were defined according to Kidney Disease Improving Global Outcomes (KDIGO) 2012 recommendations and patients were categorized according to estimated glomerular filtration rate and albuminuria status. We calibrated the RRT modelling against historical trends from country-specific renal registries. We conducted model validation and calibration using established methods for health economic modelling. Here, we report the results from the US and Canada analyses, with further analyses currently underway for additional countries in the Americas and Asia-Pacific region. Results Initial results for the US and Canada revealed that, between 2020 and 2025, annual healthcare costs associated with CKD will increase linearly from US$232.3B to US$376.2B in the US and from C$21.4B to C$34.1B in Canada (this figure does not include complication costs). In the US, the largest absolute increase in cost was observed in CKD stage 3a ($98.4B); however, CKD stage 4 had the largest relative increase in cost with an approximately three-fold increase (US$7.30B to US$23.3B). In Canada, the largest absolute increase in cost was observed in CKD stage 3a (C$5.84B); whereas CKD stage 5 had the largest relative increase in cost with an approximately five-fold increase (C$0.27B to C$1.41B). By 2025, costs associated with CKD will increase across all age categories (18–34, 35–64 and 65+ years) in both countries. In the US, the 35–64 age group had the largest absolute increase in costs with an increase of $74B (US$58.3B to US$132B). The largest relative increase in cost was observed in the 18–34 age category, with approximately a three-fold increase in costs (US$3.76B to US$10.2B). In Canada, the 65+ age group had the largest absolute increase in costs with an increase of C$7.9B (C$16.4B to C$24.3B). Both the 18–34 and 35–64 age categories had the largest relative increase in costs, with an approximately two-fold increase (C$0.25B to C$0.49B and C$4.77B to C$9.31B, respectively). Conclusion Initial results from Inside CKD demonstrate that CKD poses a significant economic burden over the next 5 years. CKD stage 3a was associated with the most pronounced cost increases in both the US and Canada, likely due to the increased prevalence of this stage. In the US, the largest increase in CKD costs was observed in the 35–64-year-old ‘working’ population, whereas the largest increase in Canada was observed in the 65 years old and over population. Further policy interventions aimed at early diagnosis and proactive management should be considered to slow disease progression, improve patient outcomes and reduce the economic burden associated with CKD.

Background and Aims With an estimated global prevalence of 10%, chronic kidney disease (CKD) and its associated complications place a substantial strain on healthcare systems worldwide, which is compounded by the burden of undiagnosed CKD. Early CKD diagnosis followed by guideline-recommended interventions can improve patient outcomes and reduce associated healthcare-related costs, particularly by delaying or preventing the development of complications and progression to kidney failure. Urinary albumin-to-creatinine ratio (UACR) can be used to screen for CKD, but adherence to screening recommendations is suboptimal in routine care. Inside CKD aims to model the global clinical and economic burden of CKD using country-specific, patient-level microsimulation models. We used the Inside CKD microsimulation to model the potential clinical and economic impacts of routine measurement of UACR followed by appropriate intervention in patients aged 45 years and over in the US and Canada. Method The Inside CKD microsimulation model was used to model the clinical and economic impacts associated with measurement of UACR with subsequent appropriate intervention during routine primary care visits versus current practice in individuals aged 45 years and over. The model covers the period 2020–2025. In preliminary analyses, virtual populations representing the general populations of the US and Canada were constructed using published country-specific data, including demographics, prevalence of CKD and comorbidities (type 2 diabetes, uncontrolled hypertension and heart failure), incidence of complications (heart failure, myocardial infarction, stroke and acute kidney injury) and costs associated with CKD. The model also included parameters relating to the proportion of patients who visit a primary care physician at least once a year, the proportion of patients who agreed to UACR measurements, and the diagnostic sensitivity and specificity of UACR measurements. The modelling is being expanded to additional countries in the Americas and the Asia-Pacific region. Results Preliminary results from the US and Canada show that over the 2020–2025 period routine measurement of UACR during primary care visits followed by appropriate intervention could prevent progression to CKD stages 3b–5 in approximately 1.3M patients in the US and 160 000 in Canada, compared with current clinical practice, with linear increases in the cumulative numbers of prevented cases (Figure). Associated savings in healthcare costs in 2025 are projected to be approximately US$16B in the US and C$2.5B in Canada, corresponding to a reduction in cost for that year of 4.4% and 7.4%, respectively, compared with current clinical practice. Conclusion Preliminary results from the Inside CKD microsimulation model in the US and Canada show that routine measurement of UACR with subsequent intervention in primary care would prevent progression to CKD stages 3b–5 in a substantial number of patients compared with current screening practices, and could therefore decrease associated healthcare costs considerably. This analysis is being extended to further countries in the Americas and the Asia-Pacific region.

Background and Aims The malnutrition-inflammation-complex (MIC) is a risk factor for mortality and lower quality of life in haemodialysis (HD) patients. The identification of MIC and its risk factors, which include the limited ability to perform functional status (FS), is key to improve the patient experience on HD. Our study investigates the association of MIC and FS combinations with mortality in HD patients. Method We analysed data from a cohort of 5465 HD patients from Australia, France, Germany, Italy, Japan, New Zealand, Spain, Sweden, and United Kingdom, enrolled in the Dialysis Outcomes and Practice Patterns Study phases 4 (2009-2011) and 5 (2012-2015). MIC syndrome was defined as low serum albumin (3mg/L in Japan; >10 mg/L elsewhere). Poor functional status was defined as the sum of scores from the self-reported limitations in the Katz Index of Independence in Activities of Daily Living (score ranges from 0 to 5) and the Lawton-Brody Instrumental Activities of Daily Living Scale (score ranges from 0 to 8) less than 11. We investigated the association between combinations of MIC (+/-) and FS (low/high) with death, using Cox proportional hazards models adjusted for possible confounders including patient demographics, comorbidity history, catheter use, serum creatinine, phosphorus levels, WBC count, haemoglobin level, and time on dialysis therapy. Results The prevalence of different combinations were: MIC-/High FS 57%, MIC-/Low FS 24%, MIC+/High FS 9%, and MIC+/Low FS 10%. Patients with MIC-/high FS were younger, better nourished, and had lower prevalence of comorbidities. Compared to this reference group, the adjusted hazard ratios [HR (95% CI)] for all-cause mortality were 1.56 (1.24-1.98) for MIC-/ low FS, 1.75 (1.32-2.32) for MIC+/ high FS, and 2.97 (2.31-3.82) for MIC+/ low FS groups. The adjusted HRs for infection-related mortality were 1.57 (0.91, 2.71) for MIC-/low FS, 1.67 (0.84, 3.31) for MIC+/High FS, and 5.45 (3.15, 9.45) for MIC+/low FS groups. Conclusion The combination of MIC and low FS is a strong predictor of mortality, and infectious mortality in particular, in HD patients. Identification of patients with MIC and FS status may plausibly help to direct interventions to improve patients’ experiences and lessen adverse clinical outcomes in the HD setting.

Background and Aims In 2012, the Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommended categorising and prognosticating chronic kidney disease (CKD) based on estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR). Contemporary studies describing the prevalence and characteristics of patients with CKD categorised according KDIGO 2012 and how studies of new pharmacotherapies relate to these categories are scarce. One such new therapy class of key interest are the sodium glucose co-transporter 2 inhibitors (SGLT-2i), shown to delay the progression to renal failure and prevent cardiovascular/renal death in patients with CKD. We aimed to describe patient characteristics and the prevalence of CKD according to the 2012 KDIGO categories in a large real-world US cohort of patients with CKD (part A). We also describe a subset of the population according to the DAPA-CKD trial inclusion criteria (eGFR [25-75ml/min/1.73m2] and UACR [200-5000mg/g]) (part B). Method DISCOVER-CKD is an international observational study in patients with CKD. The DISCOVER-CKD retrospective US cohort of patients was extracted using real-world data from the integrated Limited Claims and Electronic Health Record data (IBM Health, Armonk, NY) and HealthVerity. Patients were aged ≥18 years, with ≥1 UACR measure. For part A, required first diagnostic code of CKD (Stages 3A, 3B, 4, 5, or ESRD) or two eGFR of Results Of the overall study cohort (N=4330, 49.1% women, mean age 65.3±10.64 years), by KDIGO categories (part A): 85.7% (n=3601) had normal to mildly increased albuminuria, 11.0% (n=463) had moderately increased albuminuria and 3.3% (n=137) had severely increased albuminuria (Figure 1). 4.6% (n=193) fulfilled DAPA-CKD trial inclusion criteria (part B). In both populations, the most common comorbidities were hypertension (HTN, 73.0% for both) and type 2 diabetes (T2D, 57.6% and 56.2%, respectively). Anti-hypertensive drugs were frequently used (76.4% and 76.9%, respectively). Conclusion This study, utilising real-world data, adds to the scarcity of knowledge reporting the characteristics of patients with CKD in different eGFR and UACR strata according to the KDIGO 2012 definitions. We observed a trend in higher UACR in the group of patients with lower eGFR and report a high prevalence of T2D and HTN in the study population, demonstrating the high co-morbidity burden in patients, for whom new therapies may be beneficial.

Background and Aims Due to the interplay of chronic kidney disease and the heart, it is common for myocardial damage and strain to be present in patients with end stage kidney disease. The cardiac biomarkers Troponin I (cTnI) and the N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP) are strongly predictive of heart failure in the general population, however the value of their routine measurement for stratification of risk in hemodialysis (HD) patients is unknown. International DOPPS data indicate that these cardiac biomarkers are measured in fewer than 2% of hemodialysis patients in real-world practice. We sought to test the associations of cTNI and NT-proBNP with death in a large HD cohort. Method We analyzed data from 1169 prevalent Japanese hemodialysis patients in DOPPS phase 5 (J-DOPPS; 2012-2015) where pre-dialysis levels of cTnI and NT-proBNP at study enrollment by protocol for all participants. We used Cox regression to test the association of the cardiac biomarkers with all-cause mortality, adjusting for potential confounders. We conducted stratified analyses to assess potential effect modification of individual clinical characteristics: age, systolic blood pressure, dialysis vintage, diabetes mellitus, cardiovascular disease, and heart failure (CHF). Results Median (interquartile range) cTnI and NT-proBNP levels were 0.018 [0.005, 0.04] ng/mL and 3432 [1580, 8017] pg/mL, respectively. There was a positive direct association between cTNI and NT-proBNP (Spearman correlation coefficient=0.58). We observed 174 deaths during a median [IQR] follow-up time of 2.8 [2.3, 2.9] years. Compared to the reference group of cTNI0.04. Compared to the reference group of NT-proBNP 4000 to 8000 pg/mL; and 3.23 (1.71, 6.09) for NT-proBNP > 8000pg/mL. For both variables associations with mortality were comparable in patients with and without heart failure (p values for interaction=0.07 and 0.19, for NT-proBNP and cTNI, respectively) and according to other stratification variables (the p values for interaction were >0.15 for all other stratified models). Conclusion Routinely measured (not by indication) NT-proBNP and Troponin I are strongly associated with mortality among prevalent Japanese HD patients. Routine evaluation of these cardiac biomarkers in HD patients with or without a previous diagnosis of CHF may help identify patients at risk of death who may have undetected heart failure or cardiac strain due to fluid overload.