Vascular access

Le résumé fourni par la source

Introduction and Aims: Although several studies have demonstrated survival and economic advantages of peritoneal dialysis (PD) over haemodialysis (HD), there are few reports comparing the costs of HD and PD access care in the literature. The aim of our study was to compare the resources required to establish and maintain the dialysis access in patients who initiated HD with a tunneled cuffed catheter (TCC) or an arteriovenous fistula (AVF) with those initiating PD. Methods: A retrospective cost-effectiveness analysis was performed among 152 chronic kidney disease patients who consecutively initiated outpatient dialysis in our institution in the year 2008 (HD-AVF, n=65; HD-TCC, n=45; PD, n=42), using an intent-to-treat approach. The study was performed from the Public Administration perspective. Detailed clinical information regarding dialysis access-related interventions and morbid-mortality were collected, at year 1. Dialysis access costs were estimated using a micro-costing approach. Multivariate regression analysis was used to assess the impact of various comorbid factors on the outcomes of interest (dialysis access-related interventions, costs and mortality). Costs are reported in 2010 Euros (€). Results: HD patients were more likely to be older (p<0.001), to have a higher frequency of diabetes mellitus (p=0.048), coronary heart disease (p<0.040) and cerebrovascular disease (p<0.040). Compared with PD, HD-TCC and HF-AVF modalities were associated with a higher number of access-related infectious and mechanical complications, respectively (p=0.004 and p<0.001, respectively). The mean numbers of access surgeries and diagnostic imaging studies were highest for HD-AVF modality (p=0.083 and p<0.001, respectively), whereas the mean numbers of catheter-related invasive procedures and hospitalizations were highest for HD- TCC modality (p<0.001 and p=0.025, respectively). Overall, PD was associated with a significant lower risk of access-related interventions, compared to HD-AVF (β=-1.11, 95%CI [-1.31 to -0.31]; p=0.007) and HD-TCC modalities (β= -0.94, 95%CI [-1.91 to -0.03]; p=0.050). The costs related to dialysis access for PD, HD-AVF and HD-TCC patients were €1171.6 (95%CI [737.6-1526.0]), €1555.2 (95%CI [974.0-2136.2]) and €4208.2 (95%CI [2050.7-6365.9]) per patient-year, respectively (p<0.001). Although access surgery costs were higher for PD modality (p<0.001), diagnostic imaging procedures and catheter-related interventions were higher for HD-AVF and HD-TCC modalities, respectively (p<0.001 and p=0.010, respectively). Overall, PD was associated with €326 and €2705 per patient-year access-related cost savings, compared to HD-AVF (β=-326, 95%CI [-2560 to 1908]; p=0.774) and HD-TCC modalities (β=-2705, 95%CI [-5405 to -4]; p=0.048), respectively. During the entire period of follow-up, HD-TCC patients had a higher risk for both all-cause and access-related mortality, compared with patients on PD (adjusted OR for all-cause mortality of 16.7, p=0.040; HR for access-related mortality of 7.0, p<0.001) and HD-AVF (adjusted OR for all-cause mortality of 15, p=0.038; HR for access-related mortality of 10.1, p<0.001 Conclusions: Peritoneal dialysis requires fewer resources to establish and maintain the dialysis access compared to HD, during the first year of treatment. Our study also provides evidence for the higher risk of death associated with the use of HD catheter, compared to both AVF and PD catheter.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.