Economic evaluation of continuous renal replacement therapy in acute renal failure

Objectives: Controversy exists regarding the optimal method of providing dialysis in critically ill patients with acute renal failure. We sought to determine the cost-effectiveness of treatment strategies. Methods: Adult subjects requiring renal replacement therapy in a critical care setting who are candidates for intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) were considered within a Markov model. Alternative strategies including IHD, and standard or high dose CRRT were compared. The model considered relevant clinical and economic outcomes, and incorporated data on clinical effectiveness from a recent systematic review and high quality micro-costing data. Results: In the base-case analysis, CRRT was associated with similar health outcomes but higher costs by ($3,679 more than IHD per patient). In scenarios considering alternate cost sources, and higher intensity of IHD (including daily and longer duration IHD), CRRT remained more costly. Sensitivity analysis indicated that even small differences in the risk of mortality or need for long-term chronic dialysis therapy among surviving patients benefits led to dramatic changes in the cost-effectiveness of the modalities considered. Conclusions: Given the higher costs of providing CRRT and absence of demonstrated benefit, IHD is the preferred modality in critically ill patients who are candidates for either IHD or CRRT, although this conclusion should be revisited if future clinical trials establish differences in clinical effectiveness between modalities. Future interventions that are proven to improve renal recovery after acute renal failure are likely to be cost-effective, even if very resource intensive.