Cost-effectiveness of protein restricted diets in advanced CKD

Background The costs of dialysis are not sustainable everywhere, resulting in many avoidable deaths. Interventions that postpone the start of dialysis can save money and lives. This study evaluates the costs associated with protein-restricted diets (PRD) in chronic kidney disease (CKD). Methods CKD/4–5 patients adhering to PRD [0.3 g/kg/day, supplemented very-low protein diet (sVLPD); 0.6 g/kg/day, low protein diet (LPD)] and controls on free diet were followed for 5 years, assessing direct and indirect costs. Theoretical and observed analyses compared the estimated and actual costs. Results A total of 223 subjects under PRD and 1248 controls (CON) were studied; 62 PRD adhering to the diet and 123 propensity-matched CON entered the analyses. In PRD and CON, median survival to end-stage kidney disease (ESKD) was 48.6 [95% confidence interval (CI) 33.8–72] and 28.8 (95% CI 25–41.7) months (P =.017), and median survival to death was 107 (95% CI 96.2–114.5) and 86.6 (95% CI 66.3–103.8) months (P =.004). The monthly costs per patient were 383 euros (€) for CON, 507 € for LPD (+32%) and 767 € for sVLPD (+100%); dialysis monthly costs were 4.150 € (+980%, +720%, +440% vs CON, LPD, sVLPD). By the theoretical model, the individual costs of PRD vs CON were higher in the short follow-up (8255 vs 4595 €/year, +80%), but lower in the long follow-up (8257 vs 23048 €/year, –64%). At the observed model, which comprises both ESKD and deaths, the costs of PRD were lower either in the short (14754 vs 21208 €/year, –30%), or in the long follow-up (21764 vs 30089 €/year, –28%). Conclusions In patients adherent to diet prescription, PRD delay the start of dialysis, improve survival and save money.