Cost-Effectiveness of Standard vs. Accelerated Kidney Replacement Therapy in Acute Kidney Injury

Fresh research suggests that standard initiation of kidney replacement therapy (KRT) may be a cost-effective approach for critically ill patients with severe acute kidney injury (AKI) in Canada, though this finding is influenced by post-discharge costs and regional variations in KRT dependence. The findings stem from an economic evaluation utilizing data from the landmark STARRT-AKI trial.

Understanding the STARRT-AKI Trial

The Standard versus Accelerated Initiation of Renal-Replacement Therapy in AKI (STARRT-AKI) trial was a multinational, open-label, randomized clinical trial designed to compare two strategies for KRT initiation in critically ill patients experiencing severe AKI. The trial, conducted between October 2015 and September 2019, investigated whether an accelerated strategy – commencing KRT even without conventional indications – would improve outcomes compared to a standard approach, where KRT was initiated only when traditional criteria were met .

Researchers found that routine accelerated KRT initiation did not save lives and increased treatment exposure and harms .

Economic Evaluation Methodology

Jeff Round, PhD, and colleagues conducted an economic evaluation using data from the STARRT-AKI trial. They developed a state-transition model to estimate the cost-utility and cost-effectiveness of accelerated versus standard KRT initiation. The model incorporated four health states: no chronic kidney disease, severe chronic kidney disease, KRT dependence, and death .

The analysis included 146 participants randomly assigned to either accelerated or standard KRT initiation. The accelerated initiation group (n=73) had a mean age of 59.67 years, with 71.3% being male. The standard initiation group (n=73) had a mean age of 61.8 years, with 65.8% being male .

Key Findings: Cost and Quality of Life

The study revealed that standard initiation was more costly per patient (mean $251,370) compared to accelerated initiation (mean $231,518). However, standard initiation generated more quality-adjusted life years (QALYs) – a measure of health-related quality of life – with a mean of 7.49 QALYs versus 6.64 QALYs for accelerated initiation .

The incremental cost-effectiveness ratio (ICER) for standard initiation was $23,208, with an incremental net monetary benefit (INMB) of $22,648, assuming a willingness-to-pay threshold of $50,000 per QALY gained .

Implications for Clinical Practice

The researchers concluded that standard KRT initiation may be cost-effective in a Canadian setting. However, they emphasized that this finding is sensitive to post-discharge cost trajectories and regional variations in KRT dependence .

This research provides valuable insights for healthcare providers and policymakers involved in the management of critically ill patients with severe AKI, highlighting the importance of considering both clinical outcomes and economic factors when making decisions about KRT initiation timing.