Cost-Utility Analyses of Hemodialysis, Peritoneal Dialysis, and Kidney Transplantation in Patients with End-Stage Kidney Disease: A Systematic Review.

Abstract

The global burden of end-stage kidney disease (ESKD) is rising, compelling patients to increasingly confront the choice of initiating kidney replacement therapy (KRT). Cost-utility analysis (CUA) has the advantage of incorporating patient-reported outcomes regarding KRT. The aim of this study is to summarize the CUA of hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation in patients with ESKD. A systematic search was conducted to identify relevant articles in three primary databases (PubMed, SCOPUS, and ProQuest). CUA studies of dialysis for ESKD patients from 2000 to 2023 in all countries were included. Non-full-text, non-English language, review articles, systematic reviews, and studies that did not compare distinct dialysis methods were excluded. All the information was summarized narratively. Out of the 130 studies identified, 13 met the inclusion criteria and were included in this review. Most studies demonstrated good reporting quality, with CHEERS checklist scores ranging from 75% to 96%. Kidney transplantation was consistently found to be the most cost-effective KRT, offering the highest quality-adjusted life years (QALYs) and the lowest cost per QALY in the long term, despite higher initial expenses. PD showed better cost-effectiveness than HD in several studies. HD generally incurred the highest costs with lower QALY gains. Cost-effectiveness trends varied depending on regional context, healthcare perspective, and patient comorbidities. This study found that kidney transplantation is consistently the most cost-effective kidney replacement therapy, with lower cost per QALY and improved quality-adjusted life years (QALY) in most settings. In particular, transplantation showed favorable long-term outcomes despite higher initial costs, whereas peritoneal dialysis emerged as a more cost-effective alternative to hemodialysis, especially in resource-limited settings. These findings offer practical implications for treatment prioritization and policy-making in both high- and low-resource countries.