Comparing the Net Benefits of Adult Deceased Donor Kidney Transplantation for a Patient on the Preemptive Waiting List vs a Patient Receiving Dialysis

Abstract

IMPORTANCE Preemptive kidney transplantation is the preferred treatment for end-stage kidney disease. However, deceased donor (DD) kidneys are limited, and the net benefit of allocating kidneys to a preemptively waitlisted patient rather than to a patient receiving dialysis is unclear.OBJECTIVE To estimate the net benefit and costs of allocating kidneys to preemptively waitlisted patients vs those receiving dialysis. DESIGN, SETTING, AND PARTICIPANTSThis medical decision analytical model used data from the 2020 US Renal Data System to calculate patient survival among waitlisted patients who received a DD kidney transplant. Four patients were simulated, with similar characteristics: (1) a patient on the preemptive waiting list receiving a DD transplant, (2) a patient on the preemptive waiting list never receiving a transplant, (3) a waitlisted patient already receiving dialysis (dialysis vintage <1 year) receiving a transplant, and (4) a waitlisted patient already receiving dialysis (dialysis vintage <1 year) never receiving a transplant. Annual probability of initiating dialysis (for patients 1 and 2) and duration of dialysis (for patients 3 and 4) were varied in sensitivity analyses.EXPOSURES Allocating a DD kidney to a patient on the preemptive waiting list vs the same kidney to a patient receiving dialysis for less than 1 year, with similar recipient characteristics. MAIN OUTCOMES AND MEASURESDifferences in projected quality-adjusted life-years (QALYs) and total costs. RESULTSIn a simulated patient with a mean start age of 50 years (range, 30-64 years), the patient receiving a preemptive DD transplantation experienced 10.58 (95% CI, 10.36-10.80) QALYs, and the patient on the preemptive waiting list never transplanted experienced 6.83 (95% CI, 6.67-6.99) QALYs. The patient receiving DD transplantation after less than 1 year of dialysis experienced 10.33 (95% CI, 10.21-10.55) QALYs, and the patient receiving dialysis who remained on the waiting list experienced 6.20 (95% CI, 6.04-6.36) QALYs; allocating a DD kidney to the preemptive patient added 3.75 (95% CI, 3.57-3.93) QALYs, whereas allocating the kidney to the patient already receiving dialysis added 4.13 (95% CI, 3.92-4.31) QALYs. While the estimated posttransplant survival was longest for the preemptive transplant recipient, preferentially allocating the kidney to the preemptive patient results in 0.39 (95% CI, 0.49-0.29) fewer QALYs. The net cost of preemptive transplantation was $54 100 (95% CI, $44 100-$64 100) more than transplantation to a waitlisted patient. If the rate of transitioning to dialysis was 20 (rather than 33) events per 100 patient waiting list-years, the net QALYs were −0.67 (95% CI, −0.78 to −0.56). If the patient was receiving dialysis for 3 to 4 years (vs <1 year) the net benefit was not significantly different; however, net costs were considerably higher for the preemptive option.

The Benefits of Preemptive Transplantation Using High–Kidney Donor Profile Index Kidneys

“…A recent economic evaluation suggested that preemptive transplantation may lower the overall societal benefit of deceased organ transplantation; however, that analysis did not consider the discard of high-KDPI kidneys. 29 The recent National Academies of Sciences and Engineering and Medicine consensus study report highlighted the socioeconomic disparities in access to preemptive transplantation and suggested removing preemptive wait time as a factor in organ allocation to improve equity in transplant. 30 However, a fundamental factor contributing to disparities in organ access to transplantation is the insufficient organ supply, and therefore, policy changes to improve equity that might limit organ utilization may not be helpful.…”

A Transplant-Inclusive Value-Based Kidney Care Payment Model

“…Transplantation earlier in the kidney disease process has prognostic advantages compared to any exposure to dialysis. 8 The benefit of early transplantation is commensurate with a recent survey of 605 patients waiting for a kidney transplant, focused on trade-off preferences between kidney quality and waiting time. In that study, a majority (61%) of respondents explicitly preferred shorter waiting times even at the expense of kidney quality.…”

Deceased Kidney Donor Biomarkers: Relationship between Delayed Kidney Function and Graft Function Three Years after Transplantation

“…Kidney transplantation represents the optimal choice for selected patients with endstage renal disease. Compared to dialysis, transplantation improves patient survival and quality of life and reduces cardiovascular morbidity [1][2][3][4]. For kidney transplantation, the healthcare costs are significantly lower than long-term dialysis expenses [5][6][7].…”