Cost-Effective Care of End-Stage Renal Disease: A Billion Dollar Question

Roberts, Stephen D.

doi:10.7326/0003-4819-92-2-243

Cited by 121 publications

(26 citation statements)

References 18 publications

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“…Live related renal transplantation is established as the most cost-effective treatment for ESRF [21]. The survival of transplants from living donors is significantly better than cadaveric transplants [22].…”

Section: Discussionmentioning

confidence: 99%

“…Data acquisition is speeded up by using a parallel imaging SENSE factor of 1.2. The following parameters were used: TR/TE55.9/2.7 ms, 85 u flip angle, voxel size 0.660.660.8 mm, TFE factor of 44, two signal averages and a bandwidth of 769 Hz pixel 21 . The acquisition sequence includes a slice selective inversion pulse with an inversion delay time of 325 ms, spectral pre-saturation with inversion-recovery (SPIR) fat suppression, and a regional saturation technique slab to suppress signal from the inferior vena cava, renal vein and intestines.…”

Section: Mr Data Acquisitionmentioning

confidence: 99%

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Is there a role for free breathing non-contrast steady-state free precession renal MRA imaging for assessing live donors? A preliminary study

Laurence

Ariff²,

Quest³

et al. 2012

The British Journal of Radiology

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Objective: Accurate pre-operative evaluation of renal vascular anatomy is essential for successful renal harvest in live donor transplantation. Non-contrast renal MR angiographic (MRA) techniques are potentially well suited to the screening of donors; however, their restricted imaging field of view (FOV) has previously been an important limitation. We sought to assess whether the addition of a large FOV balanced fast field echo (BFFE) steady-state free precession (SSFP) sequence to non-contrast SSFP MRA could overcome this problem. Comparison with contrast-enhanced MRA (CE MRA) and findings at surgery were performed. Methods: 22 potential renal donors each underwent SSFP and CE MRA. 11 out of 22 potential donors subsequently underwent a donor nephrectomy. Results: All images were diagnostic. Both SSFP MRA and CE MRA identified an equal number of arteries. Surgery confirmed two accessory renal arteries, both demonstrated with both imaging techniques. A third accessory vessel was identified with both techniques on a kidney contralateral to the donated organ. 6 out of 11 procured kidneys demonstrated early branch arteries at surgery, 5 out of 6 of which had been depicted on both SSFP and CE MRA. The median grading of image quality for main renal arteries was slightly better for CE MRA (p50.048), but for accessory vessels it was better for SSFP MRA. Conclusion: This pilot study indicates that by combining free-breathing SSFP MRA with large-FOV bFFE images, an accurate depiction of renal vascular anatomy without the need for intravenous contrast administration can be obtained, as compared with surgical findings and CE MRA. Living donor transplantation is becoming an increasingly important treatment option for end-stage renal failure (ESRF). The high prevalence of anatomical variants in renal vascular anatomy underscores the importance of accurate pre-operative evaluation of the vascular anatomy [1, 2], particularly in patients undergoing a laparoscopic approach, as the surgical field of view (FOV) is limited. Multiple renal arteries in the donor kidney result in a substantial increase in the risk of complications. Moreover, the presence of accessory arteries and early branches of the renal arteries, as well as variants in venous anatomy, can all affect the surgical decision for suitability for donor harvest [3,4].Although there has been some debate about the optimal imaging strategy for potential renal donors [5][6][7], with concerns raised over the ability of contrast-enhanced MR angiography (CE MRA) to detect all renal arteries [8], there is evidence to support the sole use of CE MRA for this purpose [9]. Non-contrast MRA techniques have been used for several years, but have been generally overshadowed by the more popular contrast-enhanced techniques [10]. CT angiography is a proven tool in this domain. It also has the ability to detect parenchymal abnormalities and calculi; however, its use of ionising radiation is a disadvantage that should be considered when evaluating a donor population [11,12].Balanced steady-...

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Section: Discussionmentioning

confidence: 99%

Section: Mr Data Acquisitionmentioning

confidence: 99%

Is there a role for free breathing non-contrast steady-state free precession renal MRA imaging for assessing live donors? A preliminary study

Laurence

Ariff²,

Quest³

et al. 2012

The British Journal of Radiology

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show abstract

“…They concluded that transplantation was always less expensive than hemodialysis. Although, in a strict cost analysis, ECD kidney recipients take longer to reach the break-even point and this point might not be reached consistently if allograft survival proved to be dramatically reduced in some patient cohorts, in general, utilization of DCD and ECD kidneys is still a cost-saving treatment strategy when compared to hemodialysis (26)(27)(28).…”

Section: Discussionmentioning

confidence: 99%

Outcome of Kidney Transplantation Using Expanded Criteria Donors and Donation After Cardiac Death Kidneys: Realities and Costs

Saidi

Elias

Kawai

et al. 2007

American Journal of Transplantation

172

129

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Expanded criteria donors (ECDs) and donation after cardiac death (DCD) provide more kidneys in the donor pool. However, the financial impact and the long-term benefits of these kidneys have been questioned. From 1998 to 2005, we performed 271 deceased donor kidney transplants into adult recipients. There were 163 (60.1%) SCDs, 44 (16.2%) ECDs, 53 (19.6%) DCDs and 11 (4.1%) ECD/DCDs. The mean follow-up was 50 months. ECD and DCD kidneys had a significantly higher incidence of delayed graft function, longer time to reach serum creatinine below 3 (mg/dL), longer length of stay and more readmissions compared to SCDs. The hospital charge was also higher for ECD, ECD/DCD and DCD kidneys compared to SCDs, primarily due to the longer length of stay and increased requirement for dialysis ($70 030, $72 438, $72 789 and $47 462, respectively, p < 0.001). Early graft survival rates were comparable among all groups. However, after a mean follow-up of 50 months, graft survival was significantly less in the ECD group compared to other groups. Although our observations support the utilization of ECD and DCD kidneys, these transplants are associated with increased costs and resource utilization. Revised reimbursement guidelines will be required for centers that utilize these organs.

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“…While there has been much activity there particularly on system utilization, policy decision support and public health, 3 limited evidence of implementation exists. [3][4][5][6] An example to demonstrate the potential, however, is presented by Roberts et al, 7 where it is reported that by simulating changes to the current care pathway of end-stage renal disease, shifts from medical center dialysis to either home dialysis or cadaver donor transplantation would save US$284 million per year. The literature demonstrates the application of different simulation methods-mostly Monte Carlo simulation, discrete event simulation, system dynamics (SD), and agent-based simulation-in healthcare.…”

Section: Introductionmentioning

confidence: 99%

Causal factors of low stakeholder engagement: a survey of expert opinions in the context of healthcare simulation projects

et al. 2015

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While simulation methods have proved to be very effective in identifying efficiency gains, low stakeholder engagement creates a significant limitation on the achievement of simulation modeling projects in practice. This study reports causal factors-at two hierarchical levels (i.e., primary and secondary)-that could significantly affect low stakeholder engagement in healthcare simulation projects. A self-completed questionnaire was administered online to 91 experts in the field from whom 37 responded. The results were reinforced using a bootstrapped sample (n = 1000). Data were analyzed using descriptive statistics, Kendal's tau-b correlations, and non-linear multiple regression. Based on our research, while such factors as ''communication gap'', ''stakeholders' high workload'', and ''too much complexity involved'' represent the most significant primary causal factors, some others such as ''reluctance to change'' proved interestingly insignificant. The research suggests that high-impact public health projects can exemplify the areas that will potentially generate engagement in the healthcare simulation domain.

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Cost-Effective Care of End-Stage Renal Disease: A Billion Dollar Question

Cited by 121 publications

References 18 publications

Is there a role for free breathing non-contrast steady-state free precession renal MRA imaging for assessing live donors? A preliminary study

Is there a role for free breathing non-contrast steady-state free precession renal MRA imaging for assessing live donors? A preliminary study

Outcome of Kidney Transplantation Using Expanded Criteria Donors and Donation After Cardiac Death Kidneys: Realities and Costs

Causal factors of low stakeholder engagement: a survey of expert opinions in the context of healthcare simulation projects

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