Technology and Condition
Continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD) in critically ill adult patients with acute renal failure (ARF). There are 2,445 cases of ARF requiring dialysis among critically ill Canadian patients per year.
CRRT is a more costly therapy that has theoretical advantages over standard therapy with IHD, but there is uncertainty about whether these translate into patient-relevant outcomes. CRRT is popular among some Canadian intensivists, but there are wide variations in its use across Canada.
Methods and Results
A systematic review of the clinical literature was conducted. Thirteen RCTs and large (n≥100) controlled trials comparing CRRT with IHD were selected for review. We also identified three trials comparing the submodalities of IHD and 10 trials comparing the submodalities of CRRT. A cost-utility analysis was conducted from the perspective of a Canadian third-party payer. A Markov model followed a theoretical cohort of Canadian patients for a lifetime. The systematic review did not reveal statistically significant differences in clinical outcomes between IHD and CRRT. Economic models suggested that IHD could be cost-saving or lead to additional downstream costs. Cost effectiveness is influenced by small differences inpatient survival and need for long-term dialysis.
Implications for Decision Making
- The benefit from CRRT is yet to be proven. Compared to IHD, observed differences in clinical outcomes after CRRT (dialysis dependence at study end, number of hospitalization days) were not statistically significant, but had wide confidence intervals, suggesting that meaningful clinical differences could exist. Available evidence suggests similar rates of mortality between modalities.
- IHD reduces acute-care costs. Given current CRRT usage rates of 26% to 68%, selectively funding IHD when either technology is appropriate would save $2.1 million to $6.1 million in acute-care costs. If no improvements in clinical outcomes are obtained with CRRT, its use leads to equal QALYs and an additional cost of $3,679 compared with IHD. If IHD leads to reduced mortality, it produces 0.07QALYs and additional costs of $8,541 perpatient largely due to the additional downstream costs of more long-term dialysis.
- Decisions about optimal therapy should be revisited as more information becomes available. If future studies suggest that CRRT leads to better clinical outcomes, especially a reduced risk of dialysis dependence among survivors, the cost-effectiveness of CRRT should be revisited.
This summary is based on a comprehensive health technology assessment available from CADTH’s web site (www.cadth.ca): Tonelli M, Manns B, Wiebe N, Shrive F, Pannu N, Doig C, Klarenbach S. Continuous renal replacement therapy in adult patients with acute renal failure: systematic review and economic evaluation.