The Cost of Hemodialysis in Iran
Alireza Arefzadeh, Mahboub Lessanpezeshki, Sepideh Seifi
Department of Nephrology, Imam Khomeini Hospital, Tehran University of Medical Sciences,
Tehran, Iran
ABSTRACT. The use of dialysis in patients with end-stage renal disease (ESRD) remains one of
the most resource-intensive and hence, expensive therapeutic interventions. The purpose of this
study was to assess the cost of hemodialysis (HD) in Iran. This study was conducted in the
Department of Nephrology at the Imam Khomeini Hospital of Tehran University of Medical
Sciences, Iran, between April 2006 and June 2007. Patients with ESRD on chronic HD were
involved in the study. Relevant data were collected using interview and questionnaire. Analyzed
costs included: transportation plus absence from work, treatment instruments, drugs and other
medical procedures, diet, staff salary, equipment and building support services, non-medical
supplies, depreciation of installations and equipments, depreciation of reverse osmosis (RO) and
building rent. Sixty-three patients of whom 47.7% were males and 52.3% were females, with
mean age of 47 ± 12 years were studied. The estimated cost of each HD session was about 74 US
dollars by which an annual cost of $11549 could be estimated for each patient. Transportation and
work leaves (28.9%), staff costs and salaries (21.5%), and treatment instruments (21.1%) were
among the greatest expenses. We conclude that the annual cost of dialysis in Iran is similar to
other developing countries, but significantly less than the cost in developed countries.
Keywords: Cost, End-stage renal disease, Hemodialysis, Iran
Introduction
End-stage renal disease (ESRD) is a serious
illness with significant health consequences
and high-cost treatment options.1 As seen
worldwide, the prevalence of ESRD has significantly
increased in developing countries.2 In
Iran, the prevalence/incidence of renal replacement
therapy (RRT) and ESRD have increased
from 238 and 49.9 per million population (pmp)
in 2000,3 to 357 and 63.8 pmp, respectively in
2006.4 Currently, 50% of these patients are on
hemodialysis (HD).4
The use of dialysis in patients with ESRD
remains one of the most resource-intensive and
hence, expensive therapeutic interventions.5-7
Additionally, the growing number of ESRD
patients will devour a greater proportion of
Correspondence to:
Dr. Alireza Arefzadeh
Department of Nephrology
Imam Khomeini Hospital
Tehran University of Medical Sciences
P.O. Box13185-1678, Tehran, Iran
Email: alireza.arefzadeh@gmail .com
health-care budget. Consequently, the worldwide
demand for, and cost of renal replacement
therapy (RRT) is rapidly becoming a
major burden for health-care systems. For this
reason, chronic kidney disease (CKD) and
ESRD are considered as emerging public health
problems in developing countries necessitating
changes in health-care policies.8,9 An accurate
estimate of the cost of caring for patients with
ESRD and a better understanding of the scope
and magnitude of the total economic burden of
ESRD would help in making policy decisions
and to enable ESRD programs to develop
strategies for more cost-efficient care.10 As
there are no studies on estimation of the cost
of HD in Iran, this study was performed.
Materials and Methods
Following the approval of the Institutional
Review Board, 63 patients with ESRD on
chronic HD at the Imam Khomeini Hospital of
Tehran University of Medical Sciences, Iran
between April 2006 and June 2007, were
recruited into the study. All patients were treated
with in-center HD. Patients who survived
less than three months after commencement of
HD were excluded. The frequency as well as
duration of HD was determined by the physician
based on available resources and medical
necessity.
To assess the overall cost of treating all the
patients as well as the unit cost per each dialysis
session, we collected cost data associated with
dialysis by a customized version of the method
utilized by Adomakoh et al.11 The method was
used to determine both direct (those directly
attributed to dialysis treatment) and indirect
costs (the proportion of overhead costs incurred
by hospital in providing the dialysis
service). Relevant data were collected using
interview and questionnaire. Cost analysis was
performed from ten different viewpoints as
follows:
a) Transportation cost of patients plus his/her
attendant to the dialysis center, the cost of
elapsed time, and the expenses related to
absence from work.
b) The cost of treatment instruments (e.g.
dialysis supplies like Shaldon catheter, injection
filters, and non-dialysis supplies like
printing material).
c) The cost of drugs such as erythropoietin,
all the solutions and other drugs which
were utilized during the dialysis session or
were prescribed after that, and other medical
procedures (e.g. blood transfusion,
laboratory investigations, X-rays, etc.).
d) Dietary costs.
e) Costs related to staff salaries (e.g. nursing
staff, physicians, and dietitians).
f) Non-medical supply costs (e.g. office supplies,
cleaning).
g) All equipment and building support services
including engineering (fixing and
maintenance services), and housekeeping.
h) Depreciation of installations and equipments
(e.g. dialysis machines).
i) Depreciation of reverse osmosis (RO)
machine.
Table 1. The breakdown of hemodialysis maintenance costs for each session in Iran
Cost Amount
(US$)
Proportion of
total cost
Transportation plus absence from work 21.4 28.9%
Treatment instruments 15.6 21.1%
Drugs and other medical procedures 8.7 11.7%
Dietary 1.6 2.2%
Staffs 15.9 21.5%
Equipment and building support services 3.9 5.2%
Non-medical supplies 0.1 0.1%
Depreciation of installations and equipments 2.1 2.8%
Depreciation of RO (Reverse osmosis) machine 0.3 0.3%
Building rent 4.5 6.1%
Total 74.0 100%
308 Arefzadeh A, Lessanpezeshki M, Seifi S
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Table 2. Comparison of total hemodialysis cost per patient in some countries
Country (Reference) Total RRT expenses ($US)
Mexico (13) $ 9,631
Brazil (14) $ 10,065
Barbados (12) $ 17,029
Turkey (26) $ 22,759
New Zealand (19) $ 35,270
USA (21) $ 46,000
Japan (25) $ 46,000
Canada (16) $ 76,023
Australia’s Northern Territory (18) $ 78,600
France (24) $ 78,947
j) Building rental costs.
Data were expressed as mean ± SD for quantitative
variables and percentages for categorical
variables.
Results
The mean age of the study patients was 47 ±
12 years. Among the 63 patients studied,
47.7% were males and 52.3% were females.
All study patients received three sessions of
HD weekly with duration per session varying
between two and four hours.
The breakdown of HD maintenance costs are
shown in Table 1. The cost of each session of
HD was about US $ 74 through which an
annual cost of US $ 11,549 could be estimated
for each patient. Transportation and work leaves
(28.9%), staff costs and salaries (21.5%), and
treatment instruments (21.1%) were among the
principal contributors to the expenses.
Discussion
The results of this study revealed that the
annual cost of dialysis in Iran is higher than
that in Mexico,12 about the same as in Brazil,13
but lower than the cost in countries such as
Canada,14-16 Australia’s Northern Territory,17
New Zealand,18 Greece,19 United States,20 Italy,
5,21 Spain,22 France,10,23 Japan,24 and Turkey25
(Table 2).
The differences noted in the reported cost in
different studies are very high and cannot be
explained only in terms of their annual per
capita income. True differences in cost obviously
ensue as a result of various factors including
different management protocols, inpatient
care, an older population of patients
with more co-morbid illnesses (especially in
the United States), different local labor costs,
import duties and shipping charges, tariffs,
etc.11 For instance, while drugs constituted 53%
of overall expenses of dialysis in Greece,19 we
found that they constituted only 11.7% of the
cost. The availability of full medical insurance
coverage for these patients, makes treatment
modalities available for every patient, regardless
of the socioeconomic status. In Iran, all
patients with ESRD are eligible for government-
provided medical insurance. The ESRD
management program is mainly sponsored by
The Ministry of Health (MOH) which acts
through the Management Center for Transplantation
and Special Diseases (MCTSD).5
Thus, different modalities of RRT are provided
at no charge and are accessible to all
nationals in Iran. A fixed reimbursement rate
is paid for dialysis in both public and private
hospitals.4
There are several approaches to reduce the
annual cost of RRT. Obviously, in the longterm,
the most important factor to reduce the
overall yearly cost of RRT is to reduce the
number of patients with ESRD. This goal can
be achieved by preventing the progression of
renal disease.25 In Iran, the most frequent
causes of ESRD are diabetes mellitus, hypertension,
obstructive uropathy, cystic and congenital
disorders, glomerulonephritis, urinary tract
infections, vasculitis, tubulo-interstitial nephritis
and pregnancy related.26 Early detection of
these diseases is as important as their optimal
treatment and we should place initial focus on
The cost of hemodialysis in Iran 309
strategies and treatments that slow disease
progression, to postpone the need for RRT. 4
Furthermore, considering the fact that HD is
the most common RRT modality, accounting
for 53.7% of prevalent RRT patients in Iran,3 it
is highly recommended that we try to increase
the use of peritoneal dialysis as well as live or
cadaveric donor kidney transplantation.4 Kidney
transplantation is the most cost-effective
treatment for ESRD,27-29 and offers considerable
savings and a drastic improvement in quality
of life in these patients. It has been revealed
that compared with other countries, the
cost of kidney transplantation is low in Iran.30
Since transport expenses, which are paid directly
by the patients, and work leaves constitute
the main expenditure section in Iran, as
in Spain,22 we suggest greater use of such
modalities as home dialysis or autonomous incenter
HD, which are already well developed,
and could generate significant savings. 31,32 In
addition, there is room for the use of satellite
HD units, a dialysis mode that may prove costeffective
apart from offering psychological
benefits to the patients.19,21,32,33
Several factors limit interpreting the results
of this study. Firstly, we did not consider costs
which ESRD imposes on society in terms of
production losses due to treatment requirements,
morbidity, mortality, and time spent to
care for patients. On the other hand, if compensating
mechanisms are taken into account,
the estimated productivity losses are significantly
lower but still considerable. Additionally,
differences in funding of health-care
systems, in dialysis modality utilization, and
other cost estimation techniques limit the accuracy
of comparison of our results with other
countries.
Conclusions
In summary, in our single-center study from
Iran, we found that the annual cost of dialysis
is similar to other developing countries but
significantly less than the cost in developed
countries. In future studies, further in-depth
comparison between the cost of other modalities
of treatment of ESRD like continuous
ambulatory peritoneal dialysis and cadaver/living
donor transplantation should be taken into consideration.
Acknowledgement
The authors would like to thank Farzan Institute
for Research and Technology for technical
assistance.
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