Authors' objectives:

To review systematically the literature on six major topics in dialysis therapy for patients with end-stage renal disease (ESRD).

To link clinical effectiveness with cost (resource use) in an economic analysis to assess efficiency.

To suggest implications for clinical practice and policy needs.

To indicate areas for further research.

Authors' results and conclusions: 1. Synthetic compared with cellulose-based membranes in haemodialysis treatment for ESRD The inclusion criteria were met by 22 studies. The incidence of nausea and vomiting was significantly less with synthetic than with cellulose membranes. Predialysis beta2 microglobulin concentrations were significantly lower with high-flux synthetic membranes. In a 6-year study, the incidence of amyloid disease was less with high-flux synthetic membranes. Plasma triglyceride was lower with synthetic high-flux membranes (one study) and serum albumin was higher. Whether the differences were attributable to the membrane material or to the flux is unclear. There was no other significant difference. When compared with modified cellulose membranes, the incidence of pruritus was less with synthetic membranes. The additional benefits of synthetic membranes were achieved at additional cost. 2. Bicarbonate-buffered compared with acetate-buffered dialysate in haemodialysis treatment for ESRD The inclusion criteria were met by 18 studies. There was a significant reduction with bicarbonate dialysis in the number of haemodialysis treatments complicated by headaches, nausea/vomiting, symptomatic hypotension and non-specific intolerance. There was no clear evidence of improved cardiovascular stability, lipid profile or biochemical indicators of renal bone disease. Economic evaluation showed the cost of the self-mix bicarbonate buffer to be similar to that of acetate. 3. Short-duration compared with standard-duration haemodialysis for ESRD One study with 165 patients was identified. It compared < 3.5 hours dialysis with > 3.5 hours dialysis three times a week. There was no significant difference in mortality. Hospitalisation rates were greater in the short-duration group. There was no conclusive difference in the incidence of intradialytic adverse symptoms between the groups. Blood pressure control was worse in the short-duration group. There was insufficient evidence to judge relative efficiency. 4. Continuous ambulatory peritoneal dialysis (CAPD) delivery systems: Y-set/modified Y-set versus standard spike as treatment for ESRD Six studies met the inclusion criteria. The number of patients with at least one episode of peritonitis was significantly lower in patients using Y-set delivery systems. All but one study demonstrated a significant increase in the number of months per episode of peritonitis with the Y-set delivery systems. All studies showed a significant increase in the time to first episode of peritonitis with the Y-set system. There was no significant reduction in the number of patients who suffered exit-site infections or tunnel infections with the Y-set system. No study addressed technique failure. Benefits are achievable at extra cost. 5. Continuous cycler-assisted peritoneal dialysis (CCPD) compared with CAPD as treatment for ESRD One study of 82 patients met the inclusion criteria. There were no significant differences in the number of patients with peritonitis, catheter exit-site infections or catheter tunnel infections. The mean number of peritonitis episodes per patient per year was significantly lower with CCPD. There was no significant difference in Kt/V, six-monthly serum creatinine, urea or phosphate. Fewer patients on CCPD needed to change dialysis technique but this was not statistically significant. Patient preference could not be adequately assessed because of the parallel group trial design. The estimated cost per episode of peritonitis avoided is considerable. 6. Haemodialysis compared with CAPD as treatment for ESRD No relevant RCTs were identified. Because of the poor quality of the study designs used to obtain primary data for economic analyses, it is not possible to judge whether any assumed extra benefits provided by haemodialysis are worth any extra costs that may be incurred.

Authors' recommendations: The moderate benefits of high-flux synthetic membranes are currently achieved at additional cost. For general use, cellulose (particularly modified cellulose) membranes are appropriate. Synthetic membranes may be appropriate for patients experiencing persistent nausea and vomiting and for patients likely to be treated by haemodialysis for many years. The price of high-flux synthetic membranes is likely to fall in the future and policy recommendations should be kept under review. Bicarbonate dialysis is preferable to acetate dialysis for the haemodialysis of patients with ESRD, producing fewer unwanted effects at a similar cost. There is no evidence that reduced dialysis duration (< 3.5 hours three times per week) decreases mortality and it may increase morbidity. If reduced dialysis duration regimens are implemented on the basis of patient preference or assumed lower cost, their unproven safety should be explicitly acknowledged. Y-set delivery systems significantly reduce the incidence of peritonitis. Given that recurrent peritonitis is a major cause of technique failure, the additional cost is likely to be justified. CCPD showed benefit in one patient outcome but is more expensive than CAPD. It is suggested that CCPD should only be offered as an alternative to CAPD, at present, to patients for whom there is a specific indication. Data are not available to allow reliable conclusions to be drawn about the relative effectiveness and efficiency of haemodialysis and CAPD. Dialysis for ESRD intrudes greatly into people's daily lives. Informed patient preference, based on evidence of effectiveness and efficiency, should be taken into account when policy is decided.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.hta.ac.uk/924

Year Published: 1998

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk

Copyright: 1998 Queen's Printer and Controller of HMSO