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Cost-utility analysis of accelerated and standard strategies for renal replacement therapy initiation
Round, Jeff Akpinar, Ilke Yan, Charles Patel, Natasha van Katwyk, Sasha Montgomery, Carmel Wald, Ron Bagshaw, Sean M STARRT-AKI Investigators
Round, Jeff
Akpinar, Ilke
Yan, Charles
Patel, Natasha
van Katwyk, Sasha
Montgomery, Carmel
Wald, Ron
Bagshaw, Sean M
STARRT-AKI Investigators
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Epub Date
Issue Date
2025-10-03
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Abstract
Importance Little is known about the long-term costs and outcomes related to strategies for timing of initiation of kidney replacement therapy (KRT) in critically ill patients with severe acute kidney injury (AKI).
Objective To estimate the cost-utility and cost-effectiveness of accelerated KRT initiation compared with standard KRT initiation in critically ill patients with AKI.
Design, Setting, and Participants In this economic evaluation, a state-transition model was developed using data from the Standard vs Accelerated Initiation of Renal Replacement Therapy in AKI (STARRT-AKI) trial, a multicenter, multinational randomized clinical trial of critically ill patients with severe AKI conducted between October 2015 and September 2019. Trial data were linked to administrative health databases in Alberta, Canada, to estimate costs and long-term clinical outcomes. The model included 4 health states: no chronic kidney disease, severe chronic kidney disease, KRT dependent, and dead. Costs are reported in 2024 Canadian dollars. Data were analyzed from February 2022 to November 2024.
Exposure Initiation of KRT.
Main Outcomes and Measures The primary outcome for the economic evaluation was cost per quality-adjusted life-year (QALY) gained. The QALY is a combined measure of patient quality of life and length of life. Expected costs, QALYs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INMB) were estimated on the basis of 5000 Monte Carlo simulations.
Results A total of 146 patients from the STARRT-AKI trial were included in the analysis, with 73 patients (mean [SD] age, 59.67 [14.5] years; 52 men [71.3%]) randomized to receive accelerated initiation and 73 patients (mean [SD] age, 61.88 [12.9] years; 48 men [65.8%]) randomized to receive standard initiation. Standard initiation was more costly per patient than accelerated initiation (mean [SD], $251 370 [$155 801] vs $231 518 [$183 302]) but generated more QALYs (mean [SD] 7.49 [2.03] QALYs vs 6.64 [1.76] QALYs). The ICER of standard initiation compared with accelerated initiation was $23 208, with an INMB of $22 648 (95% credible interval, $15 980-$29 316) when assuming a willingness to pay per QALY of $50 000.
Conclusions and Relevance The findings of this economic evaluation suggest that standard KRT initiation may be cost-effective in a Canadian setting, but this finding was sensitive to postdischarge cost trajectories and regional variation in KRT dependence.
Citation
Round J, Akpinar I, Yan C, et al. Cost-Utility Analysis of Accelerated and Standard Strategies for Renal Replacement Therapy Initiation. JAMA Netw Open. 2025; 8 (10), article number e2535343. doi:10.1001/jamanetworkopen.2025.35343
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Research Unit
PubMed ID
41042508 (pubmed)
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Journal article
Language
en
Description
© 2026 The Authors. Published by MDPI. This is an open access article available under a Creative Commons licence.
The published version can be accessed at the following link on the publisher’s website: https://doi.org/10.1001/jamanetworkopen.2025.35343
Series/Report no.
ISSN
2574-3805
EISSN
2574-3805
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Sponsors
The STARRT-AKI trial was funded by the following sources: Canadian Institutes of Health Research (Open Operating Grant MOP142296 and Project Grant 389635), Canadian Institutes of Health Research in partnership with Baxter (Industry-Partnered Operating Grant IPR 139081), National Health Medical Research Council of Australia (Project Grant 1127121), the Health Research Council of New Zealand (Project Grant 17/204), and the National Institutes of Health Research Health Technology Assessment Program (United Kingdom; Reference Number HTA 17/42/74). Dr Bagshaw is supported by a Canada Research Chair in Critical Care Outcomes and Systems Evaluation.
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Licence for published version: Creative Commons Attribution 4.0 International