When to Start Population-Wide Screening for Chronic Kidney Disease: A Cost-Effectiveness Analysis

Abstract

Importance: Sodium-glucose cotransporter-2 (SGLT2) inhibitors have changed clinical management of chronic kidney disease (CKD) and made populationwide screening for CKD a viable strategy. Optimal age of screening initiation has yet to be evaluated.

Objective: To compare the clinical benefits, costs, and cost-effectiveness of population-wide CKD screening at different initiation ages and screening frequencies.

Design, setting, and participants: This cost-effectiveness study used a previously published decision-analytic Markov cohort model that simulated progression of CKD among US adults from age 35 years and older and was calibrated to population-level data from the National Health and Nutrition Examination Survey (NHANES). Effectiveness of SGLT2 inhibitors was derived from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial. Mortality, quality-of-life weights, and cost estimates were obtained from published cohort studies, randomized clinical trials, and US Centers for Medicare & Medicaid Services data. Analyses were performed from June 2023 through September 2024.

Exposures: One-time or periodic (every 10 or 5 years) screening for albuminuria, initiated at ages between 35 and 75 years, with and without addition of SGLT2 inhibitors to conventional CKD therapy (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers).

Main outcomes and measures: Cumulative incidence of kidney failure requiring kidney replacement therapy (KRT); life years, quality-adjusted life years (QALYs), lifetime health care costs (2024 US currency), and incremental cost-effectiveness ratios discounted at 3% annually.

Results: For those aged 35 years, starting screening at age 55 years, and continuing every 5 years through age 75 years, combined with SGLT2 inhibitors, decreased the cumulative incidence of kidney failure requiring KRT from 2.4% to 1.9%, increased life expectancy by 0.13 years, and cost $128 400 per QALY gained. Although initiation of screening every 5 years at age 35 or 45 years yielded greater gains in population-wide health benefits, these strategies cost more than $200 000 per additional QALY gained. The comparative values of starting screening at different ages were sensitive to the cost and effectiveness of SGLT2 inhibitors; if SGLT2 inhibitor prices drop due to patent expirations, screening at age 55 years continued to be cost-effective even if SGLT2 inhibitor effectiveness were 30% lower than in the base case.

Conclusions and relevance: This study found that, based on conventional benchmarks for cost-effectiveness in medicine, initiating population-wide CKD screening with SGLT2 inhibitors at age 55 years would be cost-effective.

Figure 1.. Changes in Outcomes For Population-Wide Screening Interventions^a Compared With Status Quo Case Detection and Treatment for Cohort Aged 35 Years

A. Increase in discounted life expectancy. B. Increase in discounted quality-adjusted life years (QALYs). C. Reductions in cumulative incidence of kidney failure requiring kidney replacement therapy (KRT). ^aWith SGLT2i indicates the addition of sodium-glucose cotransporter-2 inhibitors to conventional CKD therapy (anigotensin-converting enzyme inhibitors or angiotensin receptor blockers).

Figure 2.. Cost-Effectiveness Plane for Cohort Aged 35 Years

^aWith ACEi/ARBs indicates with conventional chronic kidney disease (CKD) therapy comprising of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs). ^bWith SGLT2i indicates with the addition of sodium-glucose cotransporter-2 (SGLT2) inhibitors to conventional CKD therapy.

Figure 3.. Tornado Plots of Incremental Cost-Effectiveness Ratios (ICERs) of Screening Every 5 Years Combined With Sodium–Glucose Cotransporter-2 Inhibitors (SGLT2i) For Cohort Aged 35 Years

A, Initiated at age 55 years. B, Initiated at age 35 years for a cohort with starting age of 35 years. With SGLT2i indicates with the addition of SGLT2is to conventional chronic kidney disease therapy (angiotensin-converting enzyme inhibitors or antigotensin receptor blockers). ACE indicates angiotensin converting enzyme; ARB, angiotensin receptor blocker; eGFR, estimated glomerular filtration rate; QALY, quality-adjusted life years; QoL, quality of life; UACR, urine albumin-creatinine ratio. ^aCompared with screening every 10 years from age 55 to 75 years with SGLT2i. ^bCompared with screening every 5 years from age 45 to 75 years with SGLT2i.

Figure 4.. Two-Way Sensitivity Analysis on Sodium-Glucose Cotransporter-2 Inhibitor (SGLT2i) Effectiveness and Monthly SGLT2i Costs at a Willingness-To-Pay Threshold of $150 000 per Quality-Adjusted Life Year (QALY) Gained for Cohort Aged 35 Years

HR indicates hazard ratio. ^aWith SGLT2i indicates the addition of sodium-glucose cotransporter-2 inhibitors to conventional chronic kidney disease therapy. With ACEi/ARBs indicates with conventional chronic kidney disease therapy comprising angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs).