| Abstract|| |
Reusing dialyzers is almost universal in developing countries to reduce the cost of hemodialysis (HD). Economic benefits of dialyzer reuse, when estimated only on the basis of the dialyzer and its consumables are very significant and attractive. In this study, we compared the cost of mechanical reuse of dialyzer considering all of the direct costs (medications, dialyzer, and its consumables, disinfection fluid, and hospitalization if any) in HD treatment, which if significantly different between single use and reuse, can nullify the obvious cost benefits. A total of 70 adult patients of any gender on maintenance HD at The Kidney Centre Post Graduate Training Institute for more than three months were included. Equal numbers of patients were on single use (Group A) and reuse of dialyzer (Group B). Both groups were compared for total direct costs of HD over a six months period. Average six monthly total direct cost per patient of Group A was significantly high as compared to Group B, the United States Dollar (USD) 1750.67 ± 135.31$ vs. USD 1488.50 ± 132.23$); difference USD 262.18$ (P <0.001). The total cost saving being 14.97% in Group B. Our study shows that dialyzer reuse provides a significant economic benefit and remains a means of reducing the cost of HD.
|How to cite this article:|
Qureshi R, Dhrolia MF, Nasir K, Imtiaz S, Ahmad A. Comparison of total direct cost of conventional single use and mechanical reuse of dialyzers in patients of end-stage renal disease on maintenance hemodialysis: A single center study. Saudi J Kidney Dis Transpl 2016;27:774-80
|How to cite this URL:|
Qureshi R, Dhrolia MF, Nasir K, Imtiaz S, Ahmad A. Comparison of total direct cost of conventional single use and mechanical reuse of dialyzers in patients of end-stage renal disease on maintenance hemodialysis: A single center study. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Oct 18];27:774-80. Available from: https://www.sjkdt.org/text.asp?2016/27/4/774/185242
| Introduction|| |
End-stage renal disease (ESRD) is a devastating medical, social, and economic problem for patients in developing countries including Pakistan. Lack of registries prevents an accurate assessment of the incidence or prevalence of ESRD, but a population-based study assessed the age-adjusted incidence at 232 cases per million population per year in India (a population very similar to Pakistan). 
The treatment for ESRD is less of a priority in cash-strapped, resource poor countries like Pakistan. Only 10% of patients needing dialysis receive this treatment.  The enormous cost of therapy limits the continuation of treatment and it is common for patients to reduce the dialysis frequency as financial resources dwindle, leading ultimately to discontinuation of dialysis and death. 
As a result of economic constraints, most developing countries reduce per dialysis cost by reusing dialyzers. ,,,, These cost reductions are described in number of studies and ranges between 32% and 34.6%. ,,,, In these studies, cost difference was calculated mostly on the basis of either cost of dialyzers  or mortality and hospitalization only. , When estimating individually on the basis of these limited factors, dialyzer reuse seems economically attractive. However, there are other factors amid reuse and single use, including the difference in the cost of medications (erythropoietin, activated Vitamin D, and phosphate binders), cost of mechanical reuse including disinfection fluid, along with dialyzers and its consumables, and hospitalization (if any), which if significantly different, can actually overcome the obvious cost benefits of reuse.
Dialyzer reuse has been in practice in our institution for more than a decade as the cost of one dialysis session is reduced by 27% calculated only on the basis of the dialyzer and its consumables. Though, the total direct cost difference between reuse and single use of dialyzers has not been evaluated.
There are limited studies on total direct cost estimation in developing countries. Our study compared all the components of the direct costs involved in the hemodialysis (HD) treatment. If the dialyzer reuse is found to be cost effective, it will be logical to continue reusing dialyzer in developing countries like Pakistan. In addition to the cost savings, important advantages of reusing dialyzers include less waste disposal, generating 5-30 times less garbage, less environmental impact,  and decrease in the frequency of first use syndrome  and improved biocompatibility. Likely disadvantages include breach of sterility, ineffective dialysis, alterations in membrane permeability, loss of structural integrity, exposure to minute amount of sterilizing agents,  and increased risk of infection with higher morbidity and mortality  if reprocessing and reuse does not follow the standard guidelines of dialyzer reuse. 
| Objective|| |
Our objective is to compare the mean total direct cost of conventional single use and reuse dialyzer in patients on chronic maintenance HD.
There is no difference in the mean total direct cost of conventional single use and reuse dialyzers in patients on chronic maintenance HD.
| Materials and Methods|| |
A total of 70 patients of both genders and aged 18 years or above who were on maintenance HD at The Kidney Centre Post Graduate Training Institute (Tertiary Renal Care Center) for more than three months were included in this study. An equal number of patients were on single use (Group A) and reuse dialyzer (Group B). Both groups were compared for total direct costs of HD over the period of six months.
Patients who were on single use because of medical reasons like thrombocytopenia or bleeding disorders were excluded from the study.
Total direct cost was calculated for the market cost of dialyzer and its consumables, service charges, use of erythropoietin, phosphate binders, activated Vitamin D, and expenditure on hospital admissions (if any) during the study period.
Serum hemoglobin, calcium, phosphorus, albumin, transferrin saturation, and intact parathyroid hormone (iPTH) levels were determined at the time of enrollment at three months and at the end of the study period to ascertain whether their level meets the standard KDOQI recommendations.
| Statistical Analysis|| |
This was a comparative observational study and samples were collected on the nonprobability convenience technique. Data were analyzed on SPSS version 17.0. Mean ± standard deviation was computed for age and all components of total direct costs of both dialyzers. Frequency and percentage were calculated for gender. The t-test was used to compare the total mean costs in both groups. P <0.05 was taken as significant.
| Results|| |
A total of 70 patients on maintenance HD for more than three months were included in this study. Thirty-five patients in the Group A were on single-use dialysis and 35 patients in Group B were on reuse dialysis. During the study period, all patients underwent 78 sessions of HD. The mean number of time a dialyzer was reuse in Group B was 24.1 ± 4.30.
The mean age of the patients in the Group A was 48.2 ± 13.0 years and in the Group B, 43.4 ± 10.8 years. An average age of the patients was not significantly different between groups (P = 0.172). Of the 70 patients, 33 (46.5%) were male and 37 (52.1%) were female. In the Group A, 17 patients were female and 17 were male and in the Group B, 19 were female and 16 were male. The mean weight of the patients in the Group A was 65.7 ± 10.3 kg and in the Group B, mean weight was 60.7 ± 10.1 kg. Mean systolic blood pressure in the Group A patients was 134 ± 20.2 mm Hg and mean diastolic blood pressure was 85.1 ± 9.92 mm Hg and in the Group B, mean systolic blood pressure was 130 ± 17.4 mm Hg and mean diastolic was 86.7 ± 9.84 mm Hg. Overall comparative demographic data between the Groups A and B are given in [Table 1].
The mean hemoglobin level at the start of the study in the Group A was 10.3 g/dL and in the Group B was 9.9 g/dL which was maintained throughout the study period, and doses of drugs were adjusted to keep the values according to KDOQI recommendations. In our study, hemoglobin values of the patients did not reach to the KDOQI recommended values in both group, however during study period, the difference between the values at baseline and at the end of study between both group was small [+0.2 mg/dL in Group A (P = 0.18) and −0.23 mg/ dL in Group B P = 0.15], which is statistically insignificant. Serum corrected calcium, serum phosphorus, and iPTH level during the study period were at the KDOQI recommendation [Table 2].
Mean six monthly total direct cost per patient of conventional Group A was significantly high as compare to Group B (the United States Dollar (USD) 1750.67 ± 135.31$ versus USD 1488.50 ± 132.23$; difference USD 262.18$; P = 0.0000001) as shown in [Figure 1]. Mean total direct cost of single dialysis session per patient is shown in [Figure 2]. The total direct-cost savings of 14.97% was achieved with reuse of dialyzers per patient per session. The cost savings of reuse if calculated only on the basis of dialyzer and its consumables is found to be 23.66% in our study.
|Figure 1: Mean 6 monthly direct total cost per patient in the United States Dollar.|
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|Figure 2: Mean cost of one dialysis session per patient in the United States Dollar.|
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[Table 3] shows the distribution of the total direct cost between two groups. Mean erythropoietin cost in six months period per patient was USD 416.80 ± 35.22$ in the group A and USD 458.53 ± 40.79$ in the Group B. The total dose of erythropoietin per month per patient was found to be slightly higher in the Group B compare to the Group A during the study period. The mean total cost of phosphate binders and activated Vitamin D between two groups were USD 32.94 ± 9.98$ and USD 39.19 ± 13.80$ in the Group A patients and USD 39.56 ± 11.25$ and USD 25.29 ± 9.43$ in the Group B, respectively. The mean total direct cost of dialyzers and its consumables was significantly high in the Group A than the Group B (USD 1207.97 ± 0.0$ vs. USD 485.45 ± 3.86$). The mean total direct cost of hospitalization was USD 296.62 ± 193.66$ in the Group A and USD 269.39 ± 93.34$ in the Group B. During our study period, greater number of patients in the Group A were hospitalized, however difference between Groups A and B was statistically insignificant (P = 0.757). The reasons for hospitalization in both groups are presented in [Table 4]. There were no admissions during the study period because of allergic reactions. The mean total cost of mechanical reuse in the Group B was USD 432.08 ± 0.0$.
All patients included in the study were negative for hepatitis B and hepatitis C. This was rechecked at the end of the study period and none seroconverted in either group.
Both groups were found to be comparable in terms of safety including allergic reaction, rate of hepatitis seroconversion, hospitalization, or major symptoms occurring during dialysis sessions.
| Discussion|| |
Human lifespan has increased and the number of years spent living with chronic illnesses including ESRD is increasing,  thereby, further burdening the health-care system all over the world.  This situation is more pronounced in Pakistan (and other low-and middle-income countries) where the financial resources allocated do not reflect the rates of increase in demand for this service.
In many developing countries, the cost of dialysis session is brought down by reusing the dialyzer. Dialyzer reuse is cost effective and is supported by many studies, a study conducted in Bangladesh on 24 patients concluded that dialyzer reuse up to six times does not compromise its clearance capacity or efficacy of dialyzer, and there was cost savings of up to 32%.  Another study conducted at Taiwan showed that there was cost savings of up to CAN 739 per patient per year with reuse.  A study conducted on maintenance hemodialysis patients in Riyadh, Saudi Arabia, dialyzers were used for 408 sessions with mean reuse of 6.2 ± 5.3 episodes per dialyzer. This study compared the phosphate and urea reduction ratio, heparin requirement, albumin leak in dialysate, and patient's morbidity and mortality after reuse dialysis. This study established that there was cost savings of 33% with the reuse of dialyzers with no short-term effect on patient morbidity and mortality.  Canadian study in 1993 also showed savings of up to CAN $ 3629 per patient per year with five reuses.  These studies show significant economic benefits of reuse but their results are based mainly on cost of dialyzer and its consumables only.
As after a thorough literature search we were unable to find studies which compared all the components of direct cost between dialyzer reuse and single use. We designed a study to compare all the factors that can make a difference in the true cost of the dialysis. We found that total direct cost of reuse to be beneficial, with 14.97% cost difference.
Study conducted in the USA showed that dialysis in free-standing facilities reprocessing dialyzers was associated with greater hospitalization than dialysis without dialyzer reprocessing. This greater hospitalization accounts for a large increment in inpatient stays in the USA and thus possibly nullify the resulting costs benefit of reuse.  These findings raise important concerns about potentially avoidable morbidity among HD patients. However, another study from the USA in 1998 to 1999 period concluded that reuse practices were not associated with a survival disadvantage or advantage.  We also found no significant difference in hospitalization rate between two groups (P = 0.7576).
In our study, we found that patients on the single-use dialysis had a slightly higher hemoglobin levels at the start of the study and dose of erythropoietin was slightly lower as compared to reuse group, which was maintained throughout the study period. This is contrary to what was found in a study at Croatia in 1997 which showed that when dialyzer reprocessing was performed, the erythropoietin dosage and hemoglobin level remained unchanged if compared with the subgroup treated with single-use dialyzers.  The result of our study may suggest better erythropoietin responsiveness in single-use dialysis as compared to reuse. Increase dose of heparin and disinfection chemicals is the major difference in dialyzer reuse and single use and may have role in lower hemoglobin level and decrease erythropoietin responsiveness in dialyzer reuse group. This finding needs to be further studied on a larger population over a longer period of time before coming to any conclusion.
All patients included in our study were negative for hepatitis B, hepatitis C, and none seroconverted in either group during study period. This finding is supported by several studies , in past that also found no significant difference in seroconversion rate of hepatitis B and C between dialyzer reuse and single use.
The above discussion and results of our study suggest that dialyzer reuse is an effective cost saving approach, especially in the face of cost inflation and limited medical resources without compromising safety in term of allergic reaction, rate of hepatitis seroconversion, hospitalization, or major symptoms occurring during dialysis sessions. However, in our study, adequacy of dialysis was not evaluated which may be an additional important factor.
Lack of standards for reprocessing dialyzer in resource-limited settings, breach in protocols for reusing, and lack of reprocessing policy can be the factors that may work against the success of reuse. To avoid potential adverse consequences, careful attention must be paid to ensure that reprocessing and reuse follow the standard guidelines of dialyzer reuse so that the economic benefits of reprocessing are maintained and reuse-related complications decrease with no compromise on safety and efficacy.
| Limitations of the study|| |
This study was not powered enough to evaluate the differences between the study groups in terms of symptoms during the dialysis sessions. In our study, the total number of patients included was only 70 and if a similar study is conducted with a larger number of patients and with the collaborations of many hospitals, more significant results would be obtained.
| Ethical issues|| |
Principles laid down by the Helsinki Declaration were observed. All participants were duly informed and made their free choice to join the study.
| Conclusion|| |
Our study shows that compared to single use, the reuse of dialyzer is still cost effective when all components of direct cost (cost of drugs such as erythropoietin, activated Vitamin D, phosphate binders, dialyzer and its consumables, cost of hospitalization and mechanical reuse) are compared. Dialyzer reuse provides high-quality cost-effective dialysis to individuals living in countries with limited resources without compromising the safety or effectiveness of the treatment.
| Disclosure|| |
All the authors declared no conflict of interests. The results presented in this paper have not been published previously in whole or part, except in abstract format.
| Acknowledgment|| |
This study was supported by The Kidney Centre Post Graduate Training Institute.
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Murtaza F Dhrolia
The Kidney Centre Post Graduate Training Institute, 197/9, Rafiqui Shaheed Road, Karachi 75530
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]