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      Comparative Survival and Economic Benefits of Deceased Donor Kidney Transplantation and Dialysis in People with Varying Ages and Co-Morbidities

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          Abstract

          Background

          Deceased donor kidneys for transplantation are in most countries allocated preferentially to recipients who have limited co-morbidities. Little is known about the incremental health and economic gain from transplanting those with co-morbidities compared to remaining on dialysis. The aim of our study is to estimate the average and incremental survival benefits and health care costs of listing and transplantation compared to dialysis among individuals with varying co-morbidities.

          Methods

          A probabilistic Markov model was constructed, using current outcomes for patients with defined co-morbidities treated with either dialysis or transplantation, to compare the health and economic benefits of listing and transplantation with dialysis.

          Findings

          Using the current waiting time for deceased donor transplantation, transplanting a potential recipient, with or without co-morbidities achieves survival gains of between 6 months and more than three life years compared to remaining on dialysis, with an average incremental cost-effectiveness ratio (ICER) of less than $50,000/LYS, even among those with advanced age. Age at listing and the waiting time for transplantation are the most influential variables within the model. If there were an unlimited supply of organs and no waiting time, transplanting the younger and healthier individuals saves the most number of life years and is cost-saving, whereas transplanting the middle-age to older patients still achieves substantial incremental gains in life expectancy compared to being on dialysis.

          Conclusions

          Our modelled analyses suggest transplanting the younger and healthier individuals with end-stage kidney disease maximises survival gains and saves money. Listing and transplanting those with considerable co-morbidities is also cost-effective and achieves substantial survival gains compared with the dialysis alternative. Preferentially excluding the older and sicker individuals cannot be justified on utilitarian grounds.

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          Most cited references49

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          A study of the quality of life and cost-utility of renal transplantation.

          Andreas Laupacis, Paul Keown, Nancy Pus … (1996)
          The objective of this study was to assess the cost-utility of renal transplantation compared with dialysis. To accomplish this, a prospective cohort of pre-transplant patients were followed for up to two years after renal transplantation at three University-based Canadian hospitals. A total of 168 patients were followed for an average of 19.5 months after transplantation. Health-related quality of life was assessed using a hemodialysis questionnaire, a transplant questionnaire, the Sickness Impact Profile, and the Time Trade-Off Technique. Fully allocated costs were determined by prospectively recording resource use in all patients. A societal perspective was taken. By six months after transplantation, the mean health-related quality of life scores of almost all measures had improved compared to pre-transplantation, and they stayed improved throughout the two years of follow up. The mean time trade-off score was 0.57 pre-transplant and 0.70 two years after transplantation. The proportion of individuals employed increased from 30% before transplantation to 45% two years after transplantation. Employment prior to transplantation [relative risk (RR) = 23], graft function (RR 10) and age (RR 1.6 for every decrease in age by one decade), independently predicted employment status after transplantation. The cost of pre-transplant care ($66,782 Can 1994) and the cost of the first year after transplantation ($66,290) were similar. Transplantation was considerably less expensive during the second year after transplantation ($27,875). Over the two years, transplantation was both more effective and less costly than dialysis. This was true for all subgroups of patients examined, including patients older than 60 and diabetics. We conclude that renal transplantation was more effective and less costly than dialysis in all subgroups of patients examined.
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            Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipients.

            Friedrich Port, Liise K. Kayler, H B Ashby … (2007)
            Elderly patients (ages 70 yr and older) are among the fastest-growing group starting renal-replacement therapy in the United States. The outcomes of elderly patients who receive a kidney transplant have not been well studied compared with those of their peers on the waiting list. Using the Scientific Registry of Transplant Recipients, we analyzed data from 5667 elderly renal transplant candidates who initially were wait-listed from January 1, 1990 to December 31, 2004. Of these candidates, 2078 received a deceased donor transplant, and 360 received a living donor transplant by 31 December 2005. Time-to-death was studied using Cox regression models with transplant as a time-dependent covariate. Mortality hazard ratios (RRs) of transplant versus waiting list were adjusted for recipient age, sex, race, ethnicity, blood type, panel reactive antibody, year of placement on the waiting list, dialysis modality, comorbidities, donation service area, and time from first dialysis to first placement on the waiting list. Elderly transplant recipients had a 41% lower overall risk of death compared with wait-listed candidates (RR=0.59; P<0.0001). Recipients of nonstandard, that is, expanded criteria donor, kidneys also had a significantly lower mortality risk (RR=0.75; P<0.0001). Elderly patients with diabetes and those with hypertension as a cause of end-stage renal disease also experienced a large benefit. Transplantation offers a significant reduction in mortality compared with dialysis in the wait-listed elderly population with end-stage renal disease.
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              Maintenance dialysis population dynamics: current trends and long-term implications.

              Michael J Lysaght (2001)
              Despite a general recognition that treatment of end-stage renal disease (ESRD) has become a large-scale undertaking, the size of the treated population and the associated costs are not well quantified. This report combines data available from a variety of sources and places the current (midyear 2001) estimated global maintenance dialysis population at just over 1.1 million patients. The size of this population has been expanding at a rate of 7% per year. Total therapy cost per patient per year in the United States is approximately 66,000 dollars. Assuming that this figure is a reasonable global average, the annual worldwide cost of maintenance ESRD therapy in the year 2001, excluding renal transplantation, will be between 70 and 75 billion US dollars. If current trends in ESRD prevalence continue, as seems probable, the ESRD population will exceed 2 million patients by the year 2010. The care of this group represents a major societal commitment: the aggregate cost of treating ESRD during the coming decade will exceed 1 trillion dollars, a thought-provoking sum by any economic metric.
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 18 January 2012
                Volume: 7
                Issue: 1
                Electronic Location Identifier: e29591
                Affiliations
                [1 ]Centre for Kidney Research, Children's Hospital at Westmead, Westmead, Australia
                [2 ]School of Public Health, University of Sydney, Sydney, Australia
                [3 ]Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
                [4 ]Central Clinical School, University of Sydney, Sydney, Australia
                [5 ]Department of Nephrology, Christchurch Hospital, Christchurch, New Zealand
                Erasmus University Rotterdam, The Netherlands
                Author notes

                Conceived and designed the experiments: GW KH JRC JCC. Performed the experiments: GW KH JRC JCC. Analyzed the data: GW KH JRC JCC ACW AT SC NC. Wrote the paper: GW. Revised and advised on the presentation of the manuscript: ACW AT SC NC.

                Article
                Publisher ID: PONE-D-11-00343
                DOI: 10.1371/journal.pone.0029591
                PMC ID: 3261160
                PubMed ID: 22279541
                SO-VID: 59d91c6f-ccff-4038-96bf-d6ee8e70a076
                Copyright © Wong 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.
                History
                Date received : 22 December 2010
                Date accepted : 30 November 2011
                Page count
                Pages: 9
                Categories
                Subject: Research Article
                Subject: Mathematics
                Subject: Probability Theory
                Subject: Medicine
                Subject: Clinical Immunology
                Subject: Immunologic Subspecialties
                Subject: Clinical Research Design
                Subject: Epidemiology
                Subject: Nephrology
                Subject: Non-Clinical Medicine
                Subject: Health Economics
                Subject: Public Health
                Subject: Surgery
                Subject: Science Policy
                Subject: Science Policy and Economics
                Subject: Social and Behavioral Sciences
                Subject: Economics
                Subject: Health Economics
                Subject: Sociology
                Subject: Demography

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                ScienceOpen disciplines: Uncategorized

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