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Cost-effectiveness of Screening for Chronic Kidney Disease Using a Cumulative Egfr-based Statistic

Reyhaneh Zafarnejad, Qiushi Chen, Paul M. Griffin


Routine screening for chronic kidney disease (CKD) could enable timely interventions to slow down disease progression, but currently there are no clinical guidelines for screening. We aim to evaluate the cost-effectiveness of screening for CKD using a novel analytical tool based on a cumulative sum statistic of estimated glomerular filtration rate (CUSUMGFR).


Chronic kidney disease (CKD), commonly associated with diabetes or hypertension, is defined as a reduction in kidney function for at least three months of duration, measured through an estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1.73 m2 or markers of kidney damage such as albuminuria [1]. Early stages of CKD are asymptomatic in most cases [2], and if unmonitored, can progress to end stage kidney disease (ESKD) defined as having eGFR below 15 mL/min per 1.73m2 [3]. In the United States (US), CKD effects over one in seven adults and is responsible for approximately 16 deaths per 100,000 population, projected to become the fifth leading cause of death by 2040 [4].

Materials and method

We extended the CKD Health Policy Model, a previously validated and widely published microsimulation model depicting the natural history of chronic kidney disease (CKD) [20–24], by incorporating additional comorbidities to simulate disease progression, complications, and treatment outcomes for patients with CKD. A synthetic cohort with a starting age of 30 years was constructed to represent the distribution of demographics and underlying chronic conditions for the US population based on National Health and Nutrition Examination Survey (NHANES) and the United States Renal Data System (USRDS), supplemented with clinical literature [13–15].


For the status quo without screening, we projected an average of 3.576 DALYs and a total cost of $123,133 per person (Table 2). All CUSUMGFR-based screening resulted in improved health outcomes (i.e., lower DALYs or higher QALYs) with increased total costs. In comparison to the status quo, the biennial CUSUMGFR-based screening starting at age 30 resulted in 3.448 DALYs and a total cost of $126,036 per person, resulting in 0.128 DALYs averted and an incremental cost of approximately $2,903 per person compared with the status quo. If the screening was delayed until age 60, the increments in the outcomes were projected to be lower. Increasing the frequency of the screening test from biennial to annual screening policy further increased health and cost outcomes, leading to the lowest DALY of 3.404, and the highest total cost of $126,077 when starting screening from age 30.


The results of this study indicated that CUSUMGFR screening is indeed a cost-effective approach for identifying individuals at risk for ESKD through several screening strategies based on commonly used figures of $50,000 to $100,000 per DALYs-averted [48, 49]. In particular, we found that annual universal screening based on the CUSUMGFR method, as a conservative universal screening policy, is the non-dominated screening policy with a cost of less than $20,000/DALY averted.


We found annual universal screening for individuals over 30 years of age based on the CUSUMGFR method is cost-effective, with a cost of less than $20,000 per DALY-averted. Moreover, this screening approach is found cost-saving when novel treatment regimen like SGLT2 inhibitors are incorporated, and it stands as the non-dominated option compared to a variety of other screening strategies. Further, utilizing this screening policy could improve outcomes in persons with mild to moderate CKD and its complications, including anemia.

Citation: Zafarnejad R, Chen Q, Griffin PM (2024) Cost-effectiveness of screening for chronic kidney disease using a cumulative eGFR-based statistic. PLoS ONE 19(3): e0299401.

Editor: Yuri Battaglia, University of Verona: Universita degli Studi di Verona, ITALY

Received: August 30, 2023; Accepted: February 8, 2024; Published: March 13, 2024

Copyright: © 2024 Zafarnejad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Model parameters came from the literature from the National Health and Examination Survey (NHANES, These are defined in Table 1 of the manuscript. The source code for the simulation model using these parameters is available at Use of this code will allow for the replication of our findings.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.


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