Hiremath Swapnil, Akbari Ayub, Wells George A, Chow Benjamin J W
Department of Medicine (Nephrology) & Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Dr, Ottawa, ON, K1H7W9, Canada.
Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada.
Int Urol Nephrol. 2018 Aug;50(8):1477-1482. doi: 10.1007/s11255-018-1874-1. Epub 2018 Apr 23.
Contrast-induced acute kidney injury is a prominent complication following cardiac catheterization, though the risk has progressively decreased in recent times with appropriate risk stratification and use of safer contrast agents. Despite data supporting further lowering of risk with the iso-osmolar agent, iodixanol, uptake has lagged, perhaps due to increased upfront cost of this agent. We undertook an economic analysis to estimate the cost-effectiveness of a strategy utilizing iodixanol compared to using a low-osmolar contrast agent.
We created a Markov model to evaluate the two strategies, and included a differential relative risk of contrast-induced acute kidney injury, based on a systematic review of the literature. Downstream clinical events, including need for dialysis and mortality, were modeled using data from existing published literature. A third-party payer perspective was utilized for the analysis and presentation of the primary economic analysis.
The strategy of using iodixanol dominated in both the low-risk and high-risk base case analyses. However, the difference was quite small in the low-risk scenario (lifetime cost: C$678,034 vs. C$678,059 and life expectancy: 19.80 vs. 19.72 years). The difference was more marked (life expectancy 15.65 vs. 14.15 years and cost C$680,989 vs. C$682,023) in the high-risk case analysis. This was robust across most of the variables tested in sensitivity analyses.
The use of iodixanol, compared with low-osmolar contrast agents, for cardiac catheterization, results in a small benefit clinical outcomes, and in a savings in direct healthcare costs. Overall, our analysis supports the use of iodixanol for cardiac catheterization, especially in patients at high risk of acute kidney injury.
造影剂诱发的急性肾损伤是心脏导管插入术后的一个突出并发症，尽管近年来通过适当的风险分层和使用更安全的造影剂，该风险已逐渐降低。尽管有数据支持使用等渗造影剂碘克沙醇可进一步降低风险，但碘克沙醇的应用滞后，这可能是由于该造影剂前期成本较高。我们进行了一项经济分析，以评估与使用低渗造影剂相比，采用碘克沙醇策略的成本效益。
我们创建了一个马尔可夫模型来评估这两种策略，并基于对文献的系统综述纳入了造影剂诱发急性肾损伤的差异相对风险。使用现有已发表文献中的数据对包括透析需求和死亡率在内的下游临床事件进行建模。分析和呈现主要经济分析时采用第三方支付者视角。
在低风险和高风险基础病例分析中，使用碘克沙醇的策略均占主导地位。然而，在低风险情况下差异非常小（终身成本：678,034加元对678,059加元，预期寿命：19.80年对19.72年）。在高风险病例分析中差异更为显著（预期寿命15.65年对14.15年，成本680,989加元对682,023加元）。在敏感性分析中测试的大多数变量中，这一结果都很稳健。
与低渗造影剂相比，心脏导管插入术使用碘克沙醇可带来微小的临床获益，并节省直接医疗成本。总体而言，我们的分析支持在心脏导管插入术中使用碘克沙醇，尤其是在急性肾损伤高风险患者中。
