**4. Cost-effectiveness of renal replacement therapy**

Although the disease and economic burden associated with kidney diseases are increasing worldwide, there have been few international reports evaluating the cost-effectiveness of renal replacement therapy in recent years. Several recent reports have systematically reviewed the cost-effectiveness of dialysis. This section briefly introduces the contents of this study and discusses a research report on the costeffectiveness evaluation of renal replacement therapy in Japan.

The main report [14] conducted a systematic review of the costs and health outcomes of dialysis modalities between January 2000 and December 2017. The survey sources included the MEDLINE, National Health Service Economic Evaluation Database, Health Technology Assessment Database from the Center of Reviews and Dissemination, Cochrane Library, and Econlit. They identified 16 health economic evaluation reports that compared dialysis modalities from both high- and low-income countries. Two similar review papers have also been published [15, 16].

These studies examined the cost and health outcomes of multiple dialysis modalities and reported average cost-effectiveness rather than incremental costeffectiveness (ICER). Nearly all evaluations suggest that home dialysis is less costly and provides similar or better health outcomes than institutional dialysis, which is the


*NR, not reported; QALY, quality-adjusted life year; ESKD, end-stage kidney disease; KRT, kidney replacement therapy; HD, hemodialysis; PD, peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis; KT, kidney transplantation; LT, living-donor transplantation; DT, deceased-donor transplantation; ICER, incremental cost-effectiveness ratio; SA, sensitivity analysis; PAS, probabilistic sensitivity analysis; WTP, willingness-to-pay.*

**Table 2.**

*Example of the cost-effectiveness of renal replacement therapy: A systematic review. (source: Ref. [14]).*

#### *Health Economics of Renal Replacement Therapy DOI: http://dx.doi.org/10.5772/intechopen.111526*

mainstay intervention. Therefore, home dialysis, which includes both hemodialysis (HD) and peritoneal dialysis (PD), is generally more cost-effective than institutional dialysis (**Table 2**). However, there are few reports with high-quality study designs.

In Japan, some studies have preliminarily evaluated the cost-effectiveness of HD, PD, and kidney transplantation (KT) for renal replacement therapy. The results are summarized in **Table 3**. Although both reports were observational studies, and the level of evidence was not high, it is possible to estimate the level of performance of renal replacement therapy in Japan. Particularly, the analytical approach was unified using a cost-utility analysis, which is suitable for mutual comparison of the medical economics of each modality.

The most cost-effective renal replacement therapy has been PD [9]. The reason for this is a good quality of life in home care, as found in a previous study. However, the PD selection rate in Japan is approximately 9%, which is lower than that of other countries. There are several reasons for this, but the previous paper has discussed the


#### **Table 3.**

*Japanese report on the cost-effectiveness of renal replacement therapy.*

socioeconomic significance of "PD first for older adults" based on the characteristics of bacterial peritonitis, which is one of the reasons for limiting the duration of PD. Thus, there is a perspective on the sustainability of the medical system in the selection of renal replacement therapy.

KT is approximately at the same level as PD and tends to be more cost-effective [17]. Particularly, KT has the best incremental cost-utility ratio (ICUR) for renal death at 51,600 (USD/Qaly) when converted to medical costs using the exchange rate of the year of publication. Furthermore, it should be noted that the results of this study did not reflect the superiority of the treatment mechanism or the cumulative cost of transplantation medicine because of a short observation period (analysis period) of 3 years. Thus, it can be inferred that KT outperforms other modalities in terms of long-term clinical and economic performance.

HD, which accounts for the majority of renal replacement therapy in Japan, has almost the same results as the cost-effectiveness judgment criteria in the medical insurance system set by the government authorities, and as described in the previous section, its socioeconomic usefulness is significant [10]. Additionally, online HD with improved dialysate quality significantly improves the QOL and function [18]. In Japan, HD is advantageous in terms of facility access and medical management. Therefore, it is essential to select a therapy suitable for the condition and lifestyle of each patient to further develop a treatment system for ESRD.

## **5. Health economics evaluation of marginal donors**

As discussed in the previous section, KT, as a therapy for ESRD, is generally considered economically superior. Therefore, although the widespread use of KT is desired, a solution to the limitations of therapy selection (e.g., securing a donor) has long been expected. As the burden of renal failure increases in Japan, the use of marginal donors in kidney transplantation medicine is expanding. Therefore, based on the definition of a marginal donor developed in a research project, we introduce a preliminary report that verifies its medical economic usefulness through a costeffectiveness analysis.

This study [19] utilized renal transplant registry data from the Japan Society for Transplantation and Tokyo University Health Economy Big Data (TheBD). The evaluation group included marginal donors, while the control group included standard donors. The eGFR cut-off of 70 mL/min/1.73 m2 was used to separate the two. Clinical results (engraftment rate, mortality rate, etc.) were analyzed from the renal transplant registry data, and the cost elements (hospitalization and outpatients by disease) of the medical economic big data were extrapolated to the obtained results. In the cost-effectiveness analysis, total medical costs (kidney transplantation medical costs and related disease treatment costs) were used as cost indicators and life-years (LYs) were used as effect indicators. Survival analysis was performed using the Kaplan-Meier method and Wilcoxon rank-sum test.

There were 3336 marginal donors and 7960 standard donors (**Table 4**). There was no significant difference (p = 0.681) in survival between the two groups (**Figure 7**). Regarding cost-effectiveness, the standard donor group tended to be slightly better in each observation period, but there was no statistically significant difference between the two (overall:2.59 million JPY/LY/year vs. 2.48 million JPY/LY/year, p = 0.849). Multiple regression analysis revealed that donor eGFR at transplantation, recipient age at transplantation, and dialysis duration were statistically significant factors

