Cost Effective Management of CKD-MBD: AnObservational Study

Chronic Kidney Disease and Mineral Bone Disorder (CKD-MBD) is often present in dialysis patients and is associated with increased hospitalization, cardiovascular morbidity and mortality. It is manifested by abnormalities in serum calcium, phosphate, parathyroid hormone (PTH) or vitamin D metabolism. Multiple interventions that often interact are possible to change biochemical parameters. The choice of treatment can greatly affect both biochemical outcomes and possibly also cost. The aim of this study was to compare management of CKD-MBD between two centres and test whether this comparison can lead to changes in management strategy. A prospective observational study of prevalent hemodialysis patients treated in two general hospitals in the Netherlands between September 2011 and October 2012. Treatment strategies in the management of CKD-MBD, biochemical parameters and cost effectiveness were compared. After the comparison, measures were taken in one hospital to improve cost effectiveness without compromising biochemical outcomes, increasing the total calcium load, or depleting patients from vitamin D. In September 2011, 93 patients in the MCA and 82 patients in the WFG underwent intermittent hemodialysis. In both hospitals, CKB-MBD was managed according to KDIGO guidelines. Albumin-corrected calcium and phosphate levels were similar, while PTH was higher in the MCA at both time points. Average daily elemental calcium supplementation per patient did not differ significantly between the hospitals, though it was slightly higher in the WFG. On the contrary, within the group of patients who were prescribed calcium-based phosphate binders, the mean dose of calcium was significantly higher in the WFG (1.7 g/pt/day vs 0.7 g/pt/day in the MCA in September 2012). The total costs of treatment of CKB-MBD in euro per patient per day in the MCA and WFG differed significantly at baseline (11 vs 4 euro), but not one year thereafter (4.50 vs 5.00 euro). In conclusion, considerable differences in CKD-MBD management can exist within KDIGO guidelines. In the absence of randomized trials, comparison of management strategies between centres can help to improve care. Cost effective management of CKB-MBD is possible without increasing calcium load or depleting patients from vitamin D.