Kailash K. Jindal

Economic appraisal of maintenance parenteral iron administration in treatment of anaemia in chronic haemodialysis patients

BACKGROUND Iron deficiency is common in haemodialysis patients and adequate supplementation by the oral or parenteral route has been limited by drug side-effects, absorption, and cost. Intermittent doses of intravenous iron dextran complex are recommended in patients with inadequate iron stores despite maximal tolerated oral dose. We conducted a prospective study with economic analysis of a regular maintenance intravenous iron regimen in this group of patients. METHODS Fifty patients comprising one-half of our haemodialysis population required intravenous iron treatment, i.e. they failed to achieve an arbitrary goal serum ferritin 100 microg/l despite maximal tolerated oral iron dose. After a loading dose of intravenous iron dextran complex (IV-FeD) based on Van Wycks nomogram (400+/-300 mg) they received a maintenance dose of 100mg IV-FeD once every 2 weeks. Initial goal serum ferritin was set at 100-200 microg/l. If no increase in haemoglobin was achieved at this level, transferrin saturation was measured to assess bioavailable iron, and when less than 20%, goal serum ferritin was increased to 200-300 microg/l. Recombinant human erythropoietin (rHuEpo) was used where needed to maintain haemoglobin in the 9.5-10.5 g/l range only if ferritin requirements were met. Results. Mean haemoglobin rose from 87.7+/-12.1 to 100.3+/-13.1 g/l (P<0.001, Cl 7.7-17.9) at mean follow-up of 6 months (range 3-15 months). In patients on rHuEpo, dose per patient was reduced from 96+/-59 u/kg per week to 63+/-41 u/kg per week, representing a 35% dose reduction (P<0.05, Cl 1-65). An annual cost reduction of

Screening to prevent renal failure in insulin dependent diabetic patients: an economic evaluation

3166 CDN was projected; however, in the first year this is offset by the cost of the loading dose of IV-FeD required at the beginning of treatment. No adverse reactions were encountered. CONCLUSION Iron deficiency is very common in our haemodialysis population, especially in those patients receiving rHuEpo. A carefully monitored regimen of maintenance parenteral iron is a safe, effective, and economically favourable means of iron supplementation in patients with insufficient iron stores on maximum tolerated oral supplements.

Experience with not offering dialysis to patients with a poor prognosis

Abstract Objective:To examine the conditions necessary to make screening for microalbuminuria in patients with insulin dependent diabetes mellitus cost effective. Design:This economic evaluation compared two strategies designed to prevent the development of end stage renal disease in patients with insulin dependent diabetes with disease for five years. Strategy A, screening for microalbuminuria as currently recommended, was compared with strategy B, a protocol in which patients were screened for hypertension and macroproteinuria. Intervention:Patients identified in both strategies were treated with an angiotensin converting enzyme inhibitor Setting:Computer simulation Main outcome measures: Strategy costs and quality adjusted life years (QALYs). Results: The model predicted that strategy A would produce an additional 0.00967 QALYs at a present value cost of

Crescentic IgA Nephropathy as a Manifestation of Human Immune Deficiency Virus Infection

261.53 (1990 US

Should All Pima Indians With Type 2 Diabetes Mellitus Be Prescribed Routine Angiotensin-Converting Enzyme Inhibition Therapy to Prevent Renal Failure?

) per patient (or an incremental cost/QALY of

Acute myoglobinuric renal failure in a patient with IgA nephropathy

27041.69) over strategy B. The incremental cost/QALY for strategy A over B was sensitive to several variables. If the positive predictive value of screening for microalbuminuria (impact of false label and unnecessary treatment) is <0.72, the effect of treatment to delay progression from microalbuminuria to macroproteinuria is <1.6 years, the cumulative incidence of diabetic nephropathy falls to <20%, or >64% of patients demonstrate hypertension at the onset of microalbuminuria, then the incremental costs/QALY will exceed

Adipsic Hypernatremia Complicated by Hyponatremia

75000. Conclusions: Whether microalbuminuria surveillance in this population is cost effective requires more information. Being aware of the costs, recommendation pitfalls, and gaps in our knowledge should help focus our efforts to provide cost effective care to this population

Avoiding Technique Failure in Chronic Peritoneal Dialysis

Despite ongoing discussion of dialysis rationing in the nephrology community, there are little available data describing current practice in treatment selection for very ill renal patients with a poor prognosis. We report a prospective survey of end-stage renal patients referred to our Canadian regional dialysis center who were not accepted to the dialysis program on the grounds of poor prognosis and low quality of life. One quarter of patients referred during 1992 were not accepted to the program, with a mean age of 74 +/- 11 years. Patients were predominantly female and most suffered from a combination of renovascular and cardiovascular disease, with very poor functional capacity as determined by the Karnofsky scale. Nonacceptance to the dialysis program did not create legal difficulties or requests for second opinions. Based on our experience, we propose guidelines for nonacceptance of patients to dialysis programs.

Metastatic lung carcinoma mimicking acute glomerulonephritis.

A 37-year-old Caucasian male homosexual presented with hematuria and rapidly progressive acute renal failure. He was found to have proteinuria and microscopic hematuria as well as RBC casts. Investigations revealed polyclonal gammopathy with five times normal serum IgA levels as well as elevated serum IgG. Renal biopsy showed evidence of crescentic IgA nephropathy with ultrastructural changes of tubuloreticular inclusions described in HIV nephropathy. He was found to be positive for human immunodeficiency viral antibodies. Renal function improved during follow-up after two doses of 1 g each of methylprednisone. In our opinion, this is the first case of HIV-related crescentic IgA nephropathy. HIV testing should be performed more frequently in patients presenting with acute glomerular diseases.

Management of idiopathic crescentic and diffuse proliferative glomerulonephritis: Evidence-based recommendations

OBJECTIVE To determine how effective angiotensin-converting enzyme (ACE) inhibitors must be in preventing diabetic nephropathy to warrant early and routine therapy in all Pima Indians with type 2 diabetes mellitus. DESIGN A computerized medical decision analysis model was used to compare strategy 1, screening for microalbuminuria and treatment of incipient nephropathy as currently recommended with ACE inhibitor therapy, with strategy 2, a protocol wherein all patients were routinely administered an ACE inhibitor 1 year after diagnosis of type 2 diabetes mellitus. The model assumed that ACE inhibitors can block, at least in part, the pathogenic mechanisms responsible for early diabetic nephropathy (microalbuminuria). RESULTS The model predicted that strategy 2 would produce more life-years at less cost than strategy 1, if routine drug therapy reduced the rate of development of microalbuminuria by 21% in all patients. Only a 9% reduction in the rate of development of microalbuminuria was cost-effective at