Cost-effectiveness of losartan in diabetic nephropathy: a Greek perspective.

BACKGROUND: Diabetic nephropathy is the primary cause of end-stage renal disease (ESRD), which involves substantial economic burden. The primary objective of this study was to estimate the potential effect of losartan on the costs associated with ESRD in patients with diabetic nephropathy in a Greek setting. A secondary aim was to approximate the direct health care cost of renal replacement therapy (RRT) in Greece. METHODS: A cost-effectiveness analysis was performed to compare losartan with placebo in patients with type 2 diabetes and nephropathy. Clinical data were derived from the RENAAL study. All costs were calculated from the perspective of the Greek social insurance system, in 2003 euros. Future costs were discounted at 3%. The time horizon was 3.5 years. Extensive sensitivity analyses were performed. RESULTS: The reduction in the number of ESRD days over 3.5 years in patients treated with losartan reduced ESRD-related costs by 3,056.54 euros, resulting in net cost savings of 1,665.43 euros per patient. Net cost savings increase thereafter, increasing to 2,686.48 euros per patient over a period of 4.0 years. The results were robust under a wide range of plausible assumptions. The weighted mean daily cost of RRT was estimated at 90.97 euros per patient. The total economic burden of RRT for the year 2003 has been estimated at 304.773 million euros. CONCLUSIONS: This study demonstrated that treatment of patients with diabetic nephropathy in Greece with losartan is cost-effective, as it leads to important savings for the social insurance system by slowing the progression to ESRD.

Effect of nifedipine in the protection of renal function during in situ preservation.

In an experimental study on six healthy dogs both kidneys were exposed and subjected to 1 h of ischaemia by clamping both renal vessels. To the left renal artery, 300 ml of cold (4 degrees C) Euro-Collins solution in which nifedipine (Bay a 1040--20 micrograms/kg per min) was diluted, was infused for 15 min. Simultaneously 300 ml of cold Euro-Collins solution plus 20 micrograms/kg per min of placebo (Bay a 1040--placebo) was infused in the right renal artery. The 1 h of ischaemia was divided in a 15-min period of cold ischaemia and 45 min of warm ischaemia, at the end of which both clamps were removed. During the 2 h (4 X 30 min) following the removal of the clamps, urine volume, urea and creatinine clearances, urine sodium concentration, sodium fractional excretion (%) and urine/plasma osmolality ratio measurements were made and results compared to the pre-ischaemia values. Both kidneys were then removed for histological study. The nifedipine group restored diuresis of 0.43 +/- 0.23 ml/min within 30 min, while this degree of diuresis (0.64 +/- 0.16 ml/min) was achieved by the placebo group at 120 min. Urine volume as well as creatinine and urea clearances of the nifedipine group were significantly higher in all studied periods compared to the placebo group (P less than 0.01 or P less than 0.025). Urine sodium and FENa (%) were not different between the two groups, and urine/plasma osmolality ratio was above 1.1 in all studied periods for both groups. The microscopic study did not show any significant differences between the two groups. We conclude that nifedipine is effective in the protection of renal function when it is administered during experimental in situ preservation.

Plasma secretin, pancreozymin, and somatostatin-like hormone in chronic renal failure patients.

Twenty patients with chronic renal failure (CRF) and ten patients on hemodialysis were included in the study of plasma secretin and pancreozymin measurement. Plasma somatostatin-like hormone (SLH) was measured in seven patients with CRF, eight patients in continuous ambulatory peritoneal dialysis (CAPD), and ten patients on hemodialysis. Normal subjects were used as sex- and age-matched healthy controls. Plasma secretin, pancreozymin, and SLH were determined by radioimmunoassay. Basal plasma concentration of secretin and pancreozymin was found significantly increased in hemodialysis patients in comparison to controls. Also test meal induced a significant increase of both hormones in hemodialysis patients. Basal plasma SLH was found significantly increased in both predialysis and dialysis (hemodialysis, CAPD) patients in comparison to controls. Correlation between clinical gastrointestinal disturbances and elevated hormone levels was not found. We believe that more reliable plasma measurement of these hormones will help the clinical investigation of gastrointestinal pathophysiology in uremia for the future.

Bone disease in long-term hemodialysis patients with low dialysate aluminium.

The dialysis unit in Sunderland uses softener water treatment with low Al concentration (dialysate mean Al 22 micrograms/L) but employs continuous oral Al (OH)3 to control serum phosphate. Thirty-one patients, 22 males and 9 females, with a mean age of 45 years, maintained on hemodialysis for a mean of 48 months were studied. Patients had higher Al concentrations than normal controls (p less than 0.001) and the postdialysis serum Al levels were also significantly higher than the predialysis levels. Twenty-four of 31 patients had evidence of hyperparathyroidism on radiology but only 4 of 31 had fractures. From a histopathological point of view, the patients were found to have no lesions (4 patients), osteitis fibrosa alone (17 patients), and osteitis fibrosa combined with osteomalacia (5 patients). The effect of 1-alpha(OH)D3 treatment was checked by repeated bone biopsies. One case of the last group showed no improvement of osteitis fibrosa, while osteomalacia progressed to severe. We conclude that both antacids and dialysate contribute to the serum and tissue Al accumulation in Sunderland Renal Unit, where over a period of ten years only one patient developed Al-related osteomalacia.