Expanding Access to High KDPI Kidney Transplant for Recipients Aged 60 y and Older: Cost Utility and Survival

Abstract

Background: Modern organ allocation systems are tasked with equitably maximizing the utility of transplanted organs. Increasing the use of deceased donor organs at risk of discard may be a cost-effective strategy to improve overall transplant benefit. We determined the survival implications and cost utility of increasing the use of marginal kidneys in an older adult Canadian population of patients with end-stage kidney disease.

Methods: We constructed a cost-utility model with microsimulation from the perspective of the Canadian single-payer health system for incident transplant waitlisted patients aged 60 y and older. A kidney donor profile index score of ≥86 was considered a marginal kidney. Donor- and recipient-level characteristics encompassed in the kidney donor profile index and estimated posttransplant survival scores were used to derive survival posttransplant. Patients were followed up for 10 y from the date of waitlist initiation. Our analysis compared the routine use of marginal kidneys (marginal kidney scenario) with the current practice of limited use (status quo scenario).

Results: The 10-y mean cost and quality-adjusted life-years per patient in the marginal kidney scenario were estimated at $379 485.33 (SD: $156 872.49) and 4.77 (SD: 1.87). In the status quo scenario, the mean cost and quality-adjusted life-years per patient were $402 937.68 (SD: $168 508.85) and 4.37 (SD: 1.87); thus, the intervention was considered dominant. At 10 y, 62.8% and 57.0% of the respective cohorts in the marginal kidney and status quo scenarios remained alive.

Conclusions: Increasing the use of marginal kidneys in patients with end-stage kidney disease aged 60 y and older may offer cost savings, improved quality of life, and greater patient survival in comparison with usual care.

Graphical abstract

FIGURE 1.

Model overview. KDPI, kidney donor profile index.

FIGURE 2.

Ten-year patient survival by scenario.

FIGURE 3.

Incremental cost-effectiveness, marginal kidney scenario vs the status quo scenario. Each dot represents the results of a simulation, plotting the incremental cost and incremental effectiveness, and the circle represents the 95% confidence interval.

FIGURE 4.

Univariate sensitivity analysis: 10-y cost variation, status quo scenario. Each box represents the effect on mean cost per patient when the related cost input is varied by ±25%. The cost input on the y-axis corresponds to the boxes positioned in line in the figure: blue = dialysis; red = transplant, recipient all years; yellow = transplant, recipient year 1; green = transplant, recipient year 2+; purple = transplant, donor.

FIGURE 5.

Univariate sensitivity analysis: 10-y cost variation, marginal kidney scenario. Each box represents the effect on mean cost per patient when the related cost input is varied by ±25%. The cost input on the y-axis corresponds to the boxes positioned in line in the figure: blue = dialysis; red = transplant, recipient all years; yellow = transplant, recipient year 1; green = transplant, recipient year 2+; purple = transplant, donor.