The value of maintaining normokalaemia and enabling RAASi therapy in chronic kidney disease

Abstract

BackgroundPeople with chronic kidney disease (CKD) are at an increased risk of developing hyperkalaemia due to their declining kidney function. In addition, these patients are often required to reduce or discontinue guideline-recommended renin-angiotensin-aldosterone system inhibitor (RAASi) therapy due to increased risk of hyperkalaemia. This original research developed a model to quantify the health and economic benefits of maintaining normokalaemia and enabling optimal RAASi therapy in patients with CKD.MethodsA patient-level simulation model was designed to fully characterise the natural history of CKD over a lifetime horizon, and predict the associations between serum potassium levels, RAASi use and long-term outcomes based on published literature. The clinical and economic benefits of maintaining sustained potassium levels and therefore avoiding RAASi discontinuation in CKD patients were demonstrated using illustrative, sensitivity and scenario analyses.ResultsInternal and external validation exercises confirmed the predictive capability of the model. Sustained potassium management and ongoing RAASi therapy were associated with longer life expectancy (+ 2.36 years), delayed onset of end stage renal disease (+ 5.4 years), quality-adjusted life-year gains (+ 1.02 QALYs), cost savings (£3135) and associated net monetary benefit (£23,446 at £20,000 per QALY gained) compared to an absence of RAASi to prevent hyperkalaemia.ConclusionThis model represents a novel approach to predicting the long-term benefits of maintaining normokalaemia and enabling optimal RAASi therapy in patients with CKD, irrespective of the strategy used to achieve this target, which may support decision making in healthcare.Electronic supplementary materialThe online version of this article (10.1186/s12882-019-1228-y) contains supplementary material, which is available to authorized users.

Cost‐analysis of persistent hyperkalaemia in non‐dialysis chronic kidney disease patients under nephrology care in Italy

“…The findings from this study corroborate results from a recent study conducted by Evans and colleagues, which demonstrated the value of maintaining normokalaemia in CKD in terms of improved survival, delayed dialysis onset and lower cost from the perspective of the health‐care system in the United Kingdom (UK) . The agreement between the results of the current analysis based on real‐world Italian data and the study conducted in UK, seems to indicate likely generalisability of the reported predictions.…”

“…The international expert panel of Kidney Disease: Improving Global Outcomes (KDIGO) Guidelines has repeatedly brought to attention of nephrology community the importance of conservative care as rational treatment alternative to dialysis even in advanced CKD because dialysis initiation associates with a still dramatically increase in mortality, poorer quality of life in survivors, and striking hike of economic costs [30][31][32][33][34]. The findings from this study corroborate results from a recent study conducted by Evans and colleagues, which demonstrated the value of maintaining normokalaemia in CKD in terms of improved survival, delayed dialysis onset and lower cost from the perspective of the health-care system in the United Kingdom (UK) 35. The agreement between the results of the current analysis based on real-world Italian data and the study conducted in UK, seems to indicate likely generalisability of the reported predictions.…”

Clinical and Economic Burden of Hyperkalemia: A Nationwide Hospital-Based Cohort Study in Japan

“…A recent study assessed the cost-effectiveness of sustained serum potassium level control and ongoing RAAS inhibitor therapy using a patient-level simulation model in patients with CKD. 26 In this study, sustained serum potassium level control and ongoing RAAS inhibitor therapy resulted in longer life expectancy (by 2.36 years), delayed onset of end-stage renal disease (by 5.4 years), quality-adjusted life-year gains (1.04 year), and cost savings of £3,135 ($3,871) compared with the absence of RAAS inhibitor use to prevent hyperkalemia. Evidence of the cost-effectiveness of long-term serum potassium level management has become increasingly important, particularly with the recent introduction of newer potassium-binding agents such as patiromer and sodium zirconium cyclosilicate in clinical practice with improved tolerability for continuous use.…”

Hyperkalemia Among Hospitalized Patients and Association Between Duration of Hyperkalemia and Outcomes

“…The early hyperkalemia resolution is attributed to fast-acting helpful mediations administered using intravenous solutions and the control of NSAIDs. The prevalence of NSAIDs as a cause of hyperkalemia reflects the population, which has a high incidence of kidney diseases and coronary artery diseases, which are less likely to be treated NSAIDs [ 16 ]. The method of collecting data to measure exposure to drugs through the records of the drugs administered before a hyperkalemia episode is controversial [ 17 ].…”