| Abstract|| |
The use of dialysis in patients with end-stage renal disease (ESRD) remains one of the most resource-intensive and hence, expensive therapeutic interventions. The purpose of this study was to assess the cost of hemodialysis (HD) in Iran. This study was conducted in the Department of Nephrology at the Imam Khomeini Hospital of Tehran University of Medical Sciences, Iran, between April 2006 and June 2007. Patients with ESRD on chronic HD were involved in the study. Relevant data were collected using interview and questionnaire. Analyzed costs included: transportation plus absence from work, treatment instruments, drugs and other medical procedures, diet, staff salary, equipment and building support services, non-medical supplies, depreciation of installations and equipments, depreciation of reverse osmosis (RO) and building rent. Sixty-three patients of whom 47.7% were males and 52.3% were females, with mean age of 47 ± 12 years were studied. The estimated cost of each HD session was about 74 US dollars by which an annual cost of $11549 could be estimated for each patient. Transportation and work leaves (28.9%), staff costs and salaries (21.5%), and treatment instruments (21.1%) were among the greatest expenses. We conclude that the annual cost of dialysis in Iran is similar to other developing countries, but significantly less than the cost in developed countries.
Keywords: Cost, End-stage renal disease, Hemodialysis, Iran
|How to cite this article:|
Arefzadeh A, Lessanpezeshki M, Seifi S. The cost of hemodialysis in Iran. Saudi J Kidney Dis Transpl 2009;20:307-11
| Introduction|| |
End-stage renal disease (ESRD) is a serious illness with significant health consequences and high-cost treatment options.  As seen worldwide, the prevalence of ESRD has significantly increased in developing countries.  In Iran, the prevalence/incidence of renal replacement therapy (RRT) and ESRD have increased from 238 and 49.9 per million population (pmp) in 2000,  to 357 and 63.8 pmp, respectively in 2006.  Currently, 50% of these patients are on hemodialysis (HD). 
The use of dialysis in patients with ESRD remains one of the most resource-intensive and hence, expensive therapeutic interventions. ,, Additionally, the growing number of ESRD patients will devour a greater proportion of health-care budget. Consequently, the worldwide demand for, and cost of renal replacement therapy (RRT) is rapidly becoming a major burden for health-care systems. For this reason, chronic kidney disease (CKD) and ESRD are considered as emerging public health problems in developing countries necessitating changes in health-care policies. , An accurate estimate of the cost of caring for patients with ESRD and a better understanding of the scope and magnitude of the total economic burden of ESRD would help in making policy decisions and to enable ESRD programs to develop strategies for more cost-efficient care.  As there are no studies on estimation of the cost of HD in Iran, this study was performed.
| Materials and Methods|| |
Following the approval of the Institutional Review Board, 63 patients with ESRD on chronic HD at the Imam Khomeini Hospital of Tehran University of Medical Sciences, Iran between April 2006 and June 2007, were recruited into the study. All patients were treated with in-center HD. Patients who survived less than three months after commencement of HD were excluded. The frequency as well as duration of HD was determined by the physician based on available resources and medical necessity.
To assess the overall cost of treating all the patients as well as the unit cost per each dialysis session, we collected cost data associated with dialysis by a customized version of the method utilized by Adomakoh et al.  The method was used to determine both direct (those directly attributed to dialysis treatment) and indirect costs (the proportion of overhead costs in curred by hospital in providing the dialysis service). Relevant data were collected using interview and questionnaire. Cost analysis was performed from ten different viewpoints as follows:
- Transportation cost of patients plus his/her attendant to the dialysis center, the cost of elapsed time, and the expenses related to absence from work.
- The cost of treatment instruments (e.g. dialysis supplies like Shaldon catheter, injection filters, and non-dialysis supplies like printing material).
- The cost of drugs such as erythropoietin, all the solutions and other drugs which were utilized during the dialysis session or were prescribed after that, and other medical procedures (e.g. blood transfusion, laboratory investigations, X-rays, etc.).
- Dietary costs.
- Costs related to staff salaries (e.g. nursing staff, physicians, and dietitians).
- Non-medical supply costs (e.g. office supplies, cleaning).
- All equipment and building support services including engineering (fixing and maintenance services), and housekeeping.
- Depreciation of installations and equipments (e.g. dialysis machines).
- Depreciation of reverse osmosis (RO) machine.
- Building rental costs.
Data were expressed as mean ± SD for quantitative variables and percentages for categorical variables.
| Results|| |
The mean age of the study patients was 47 ± 12 years. Among the 63 patients studied, 47.7% were males and 52.3% were females. All study patients received three sessions of HD weekly with duration per session varying between two and four hours.
The breakdown of HD maintenance costs are shown in [Table 1]. The cost of each session of HD was about US $ 74 through which an annual cost of US $ 11,549 could be estimated for each patient. Transportation and work leaves (28.9%), staff costs and salaries (21.5%), and treatment instruments (21.1%) were among the principal contributors to the expenses.
| Discussion|| |
The results of this study revealed that the annual cost of dialysis in Iran is higher than that in Mexico,  about the same as in Brazil,  but lower than the cost in countries such as Canada, ,, Australia's Northern Territory,  New Zealand,  Greece,  United States,  Italy, , Spain,  France, , Japan,  and Turkey  [Table 2].
The differences noted in the reported cost in different studies are very high and cannot be explained only in terms of their annual per capita income. True differences in cost obviously ensue as a result of various factors in cluding different management protocols, inpatient care, an older population of patients with more co-morbid illnesses (especially in the United States), different local labor costs, import duties and shipping charges, tariffs, etc.  For instance, while drugs constituted 53% of overall expenses of dialysis in Greece,  we found that they constituted only 11.7% of the cost. The availability of full medical insurance coverage for these patients, makes treatment modalities available for every patient, regardless of the socioeconomic status. In Iran, all patients with ESRD are eligible for government-provided medical insurance. The ESRD management program is mainly sponsored by The Ministry of Health (MOH) which acts through the Management Center for Transplantation and Special Diseases (MCTSD).  Thus, different modalities of RRT are provided at no charge and are accessible to all nationals in Iran. A fixed reimbursement rate is paid for dialysis in both public and private hospitals. 
There are several approaches to reduce the annual cost of RRT. Obviously, in the longterm, the most important factor to reduce the overall yearly cost of RRT is to reduce the number of patients with ESRD. This goal can be achieved by preventing the progression of renal disease.  In Iran, the most frequent causes of ESRD are diabetes mellitus, hypertension, obstructive uropathy, cystic and congenital disorders, glomerulonephritis, urinary tract infections, vasculitis, tubulo-interstitial nephritis and pregnancy related.  Early detection of these diseases is as important as their optimal treatment and we should place initial focus on strategies and treatments that slow disease progression, to postpone the need for RRT. 
Furthermore, considering the fact that HD is the most common RRT modality, accounting for 53.7% of prevalent RRT patients in Iran,  it is highly recommended that we try to increase the use of peritoneal dialysis as well as live or cadaveric donor kidney transplantation.  Kidney transplantation is the most cost-effective treatment for ESRD, ,, and offers considerable savings and a drastic improvement in quality of life in these patients. It has been revealed that compared with other countries, the cost of kidney transplantation is low in Iran. 
Since transport expenses, which are paid directly by the patients, and work leaves constitute the main expenditure section in Iran, as in Spain,  we suggest greater use of such modalities as home dialysis or autonomous incenter HD, which are already well developed, and could generate significant savings. , In addition, there is room for the use of satellite HD units, a dialysis mode that may prove costeffective apart from offering psychological benefits to the patients. ,,,
Several factors limit interpreting the results of this study. Firstly, we did not consider costs which ESRD imposes on society in terms of production losses due to treatment requirements, morbidity, mortality, and time spent to care for patients. On the other hand, if compensating mechanisms are taken into account, the estimated productivity losses are significantly lower but still considerable. Additionally, differences in funding of health-care systems, in dialysis modality utilization, and other cost estimation techniques limit the accuracy of comparison of our results with other countries.
| Conclusions|| |
In summary, in our single-center study from Iran, we found that the annual cost of dialysis is similar to other developing countries but significantly less than the cost in developed countries. In future studies, further in-depth comparison between the cost of other modalities of treatment of ESRD like continuous ambulatory peritoneal dialysis and cadaver/living donor transplantation should be taken into consideration.
| Acknowledgement|| |
The authors would like to thank Farzan Institute for Research and Technology for technical assistance.
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Department of Nephrology, Imam Khomeini Hospital, Tehran University of Medical Sciences, P.O. Box13185-1678, Tehran
[Table 1], [Table 2]