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1
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Steenvoorden TS, Evers L, Vogt L, Rood JAJ, Kers J, Baas MC, Christiaans MHL, Lindeman JHN, Sanders JSF, de Vries APJ, van Zuilen AD, Bemelman FJ, Peters-Sengers H. The differential impact of early graft dysfunction in kidney donation after brain death and after circulatory death: Insights from the Dutch National Transplant Registry. Am J Transplant 2025; 25:556-566. [PMID: 39343037 DOI: 10.1016/j.ajt.2024.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 08/23/2024] [Accepted: 09/22/2024] [Indexed: 10/01/2024]
Abstract
Kidneys donated after circulatory death (DCD) perform similarly to kidneys donated after brain death (DBD). However, the respective incidences of delayed graft function (DGF) differ. This questions the donor type-specific impact of early graft function on long-term outcomes. Using competing risk and Cox-regression analysis, we compared death-censored graft loss between types of early graft function: DGF (temporary dialysis dependency started within 7 days after transplantation), slow graft function (3-day plasma creatinine decline less than 10% per day), and immediate graft function. In 1061 DBD and 1605 DCD graft recipients (January 2014 until January 2023), graft survival was similar. DGF was associated with death-censored graft loss in DBD and DCD (adjusted hazard ratios: DGF in DBD: 1.79 [1.04-2.91], P = .027, DGF in DCD: 1.84 [1.18-2.87], P = .008; Reference: no DGF). Slow graft function was associated with death-censored graft loss in DBD, but not significantly in DCD (adjusted hazard ratios DBD: 2.82 (1.34-5.93), P = .007, and DCD: 1.54 (0.72-3.35), P = .262; Reference: immediate graft function). Early graft dysfunction has a differential impact on graft outcome in DBD and DCD. The differences between DBD and DCD should be accounted for in research and the clinic.
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Affiliation(s)
- Thei S Steenvoorden
- Department of Internal Medicine, Section Nephrology, Amsterdam UMC, location AMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands.
| | - Lara Evers
- Department of Internal Medicine, Section Nephrology, Amsterdam UMC, location AMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section Nephrology, Amsterdam UMC, location AMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Janneke A J Rood
- Department of Internal Medicine, Section Nephrology, Amsterdam UMC, location VUmc, Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
| | - Jesper Kers
- Department of Pathology, Amsterdam UMC, Amsterdam Infection & Immunity Institute, University of Amsterdam, Amsterdam, The Netherlands; Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Biomolecular Systems Analytics, Van 't Hoff Institute for Molecular Sciences (HIMS), University of Amsterdam, Amsterdam, The Netherlands
| | - Marije C Baas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten H L Christiaans
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan H N Lindeman
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan-Stephan F Sanders
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Aiko P J de Vries
- Department of Medicine, Division of Nephrology, and Leiden Transplant Center, Leiden University Medical Center and Leiden University, Leiden, The Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology and Hypertension, UMC Utrecht, Utrecht, The Netherlands
| | - Frederike J Bemelman
- Department of Internal Medicine, Section Nephrology, Amsterdam UMC, location AMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Hessel Peters-Sengers
- Center of Experimental and Molecular Medicine, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Department of Epidemiology and Data Science, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
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Kramer AH, Couillard PL, Doig CJ, Kromm JA. Neuroimaging Augments DCD-N Score in Predicting Time from Withdrawal of Life-Sustaining Measures to Death Among Potential Organ Donors. Neurocrit Care 2025:10.1007/s12028-024-02204-x. [PMID: 39776350 DOI: 10.1007/s12028-024-02204-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2024] [Accepted: 12/20/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND Controlled donation after circulatory determination of death (DCD) is feasible only if circulatory arrest occurs soon after withdrawal of life-sustaining measures (WLSM). When organ recovery cannot proceed because this time interval is too long, there are potential negative implications, including perceptions of "secondary loss" for patients' families and significant resource consumption. The DCD-N score is a validated clinical tool for predicting rapid death following WLSM. We hypothesized that neuroimaging evidence of effaced perimesencephalic cisterns improves prediction of time to death compared with the DCD-N score alone. METHODS In a retrospective population-based cohort study, DCD-N scores were prospectively determined in patients for whom consent for DCD had been obtained. Perimesencephalic cisterns on last available neuroimaging were assessed in duplicate and classified as normal, partially effaced, or completely effaced. Multivariable logistic regression assessed the capacity of DCD-N score and effaced cisterns to predict death within 1, 2, or 3 h of WLSM. RESULTS Of 164 consecutive patients, 49 (30%) progressed to death by neurologic criteria and were excluded. Of the remaining 115 patients, 81 (70%) died within 2 h of WLSM. When perimesencephalic cisterns were patent, this occurred in 48% of patients, compared with 88% and 93%, respectively, of patients with partially and completely effaced cisterns (p < 0.0001). In multivariable analysis, the odds ratio for prediction of death within 2 h was 7.2 (2.8-18.3) for each incremental DCD-N score and 15.4 (4.1-58.1) for the presence of either partially or completely effaced cisterns (c = 0.92 vs. 0.75-0.84 for univariate models). Results were comparable for prediction of death within 1 or 3 h. With patent cisterns, median time to death was 132.5 (21-420) minutes, compared with 23.5 (16-32) and 22 (19-30) minutes, respectively, with partially and completely effaced cisterns (p = 0.0002). CONCLUSIONS Cerebral edema with effaced perimesencephalic cisterns predicts rapid death following WLSM in potential DCD organ donors and improves on performance of the DCD-N score alone. Although originally validated for the prediction of death within 1 h, the DCD-N score remains predictive up to 3 h following WLSM.
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Affiliation(s)
- Andreas H Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.
| | - Philippe L Couillard
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Christopher J Doig
- Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Julie A Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Give Life Alberta South Zone, Calgary, AB, Canada
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de la Plaza Llamas R, Ortega Azor L, Hernández Yuste M, Gorini L, Latorre-Fragua RA, Díaz Candelas DA, Al Shwely Abduljabar F, Gemio del Rey IA. Quality-adjusted life years and surgical waiting list: Systematic review of the literature. World J Gastrointest Surg 2024; 16:1155-1164. [PMID: 38690041 PMCID: PMC11056653 DOI: 10.4240/wjgs.v16.i4.1155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/26/2024] [Accepted: 02/25/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND The quality-adjusted life year (QALY) is a metric that is increasingly used today in the field of health economics to evaluate the value of different medical treatments and procedures. Surgical waiting lists (SWLs) represent a pressing problem in public healthcare. The QALY measure has rarely been used in the context of surgery. It would be interesting to know how many QALYs are lost by patients on SWLs. AIM To investigate the relationship between QALYs and SWLs in a systematic review of the scientific literature. METHODS The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. An unlimited search was carried out in PubMed, updated on January 19, 2024. Data on the following variables were investigated and analyzed: Specialty, country of study, procedure under study, scale used to measure QALYs, the use of a theoretical or real-life model, objectives of the study and items measured, the economic value assigned to the QALY in the country in question, and the results and conclusions published. RESULTS Forty-eight articles were selected for the study. No data were found regarding QALYs lost on SWLs. The specialties in which QALYs were studied the most in relation to the waiting list were urology and general surgery, with 15 articles each. The country in which the most studies of QALYs were carried out was the United States (n = 21), followed by the United Kingdom (n = 9) and Canada (n = 7). The most studied procedure was organ transplantation (n = 39), including 15 kidney, 14 liver, 5 heart, 4 lung, and 1 intestinal. Arthroplasty (n = 4), cataract surgery (n = 2), bariatric surgery (n = 1), mosaicplasty (n = 1), and septoplasty (n = 1) completed the surgical interventions included. Thirty-nine of the models used were theoretical (the most frequently applied being the Markov model, n = 34), and nine were real-life. The survey used to measure quality of life in 11 articles was the European Quality of Life-5 dimensions, but in 32 articles the survey was not specified. The willingness-to-pay per QALY gained ranged from $100000 in the United States to €20000 in Spain. CONCLUSION The relationship between QALYs and SWLs has only rarely been studied in the literature. The rate of QALYs lost on SWLs has not been determined. Future research is warranted to address this issue.
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Affiliation(s)
- Roberto de la Plaza Llamas
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Lorena Ortega Azor
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Marina Hernández Yuste
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Ludovica Gorini
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
| | - Raquel Aránzazu Latorre-Fragua
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | | | - Farah Al Shwely Abduljabar
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Ignacio Antonio Gemio del Rey
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
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Hedley JA, Kelly PJ, Wyld M, Shah K, Morton RL, Byrnes J, Rosales BM, De La Mata NL, Wyburn K, Webster AC. Cost-effectiveness of Interventions to Increase Utilization of Kidneys From Deceased Donors With Primary Brain Malignancy in an Australian Setting. Transplant Direct 2023; 9:e1474. [PMID: 37090124 PMCID: PMC10118354 DOI: 10.1097/txd.0000000000001474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 04/25/2023] Open
Abstract
Kidneys from potential deceased donors with brain cancer are often foregone due to concerns of cancer transmission risk to recipients. There may be uncertainty around donors' medical history and their absolute transmission risk or risk-averse decision-making among clinicians. However, brain cancer transmissions are rare, and prolonging waiting time for recipients is harmful. Methods We assessed the cost-effectiveness of increasing utilization of potential deceased donors with brain cancer using a Markov model simulation of 1500 patients waitlisted for a kidney transplant, based on linked transplant registry data and with a payer perspective (Australian government). We estimated costs and quality-adjusted life-years (QALYs) for three interventions: decision support for clinicians in assessing donor risk, improved cancer classification accuracy with real-time data-linkage to hospital records and cancer registries, and increased risk tolerance to allow intermediate-risk donors (up to 6.4% potential transmission risk). Results Compared with current practice, decision support provided 0.3% more donors with an average transmission risk of 2%. Real-time data-linkage provided 0.6% more donors (1.1% average transmission risk) and increasing risk tolerance (accepting intermediate-risk 6.4%) provided 2.1% more donors (4.9% average transmission risk). Interventions were dominant (improved QALYs and saved costs) in 78%, 80%, and 87% of simulations, respectively. The largest benefit was from increasing risk tolerance (mean +18.6 QALYs and AU$2.2 million [US$1.6 million] cost-savings). Conclusions Despite the additional risk of cancer transmission, accepting intermediate-risk donors with brain cancer is likely to increase the number of donor kidneys available for transplant, improve patient outcomes, and reduce overall healthcare expenditure.
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Affiliation(s)
- James A. Hedley
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Patrick J. Kelly
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Melanie Wyld
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia
| | - Karan Shah
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Rachael L. Morton
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Juliet Byrnes
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Brenda M. Rosales
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Nicole L. De La Mata
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Kate Wyburn
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Renal Unit, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Angela C. Webster
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
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5
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Hwang CS, Kadakia Y, Sanchez-Vivaldi JA, Patel MS, Shah JA, DeGregorio L, Desai DM, Vagefi PA, MacConmara M. Delayed graft function in pediatric living donor kidney transplantation. Pediatr Transplant 2023; 27:e14432. [PMID: 36369617 DOI: 10.1111/petr.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Pediatric recipients of living donor kidneys have a low rate of delayed graft function (DGF). We examined the incidence, risk factors and outcomes of DGF in pediatric patients who received a living donor allograft. METHODS The STARfile was queried to examine all pediatric patients transplanted with a living donor kidney between 2000 and 2020. Donor and recipient demographic data were examined, as were survival and outcomes. Recipients were stratified into DGF and no DGF groups. DGF was defined as the need for dialysis within the first week after transplant. RESULTS 6480 pediatric patients received a living donor (LD) kidney transplant during the study period. 269 (4.2%) developed DGF post-transplant. Donors were similar in age, creatinine, and cold ischemia time. Recipients of kidneys with DGF were similar in age, sensitization status and HLA mismatch. Focal segmental glomerulosclerosis (FSGS) was the most common diagnosis in recipients with DGF, and allograft thrombosis was the most common cause of graft loss in this group. Small recipients (weight < 15 kg) were found to have a significantly higher rate of DGF. Length of stay doubled in recipients with DGF, and rejection rates were higher post-transplant. Recipients of LD kidneys who developed DGF had significantly worse 1 year allograft survival (67% vs. 98%, p < .0001). CONCLUSIONS Pediatric living donor kidney transplant recipients who experience DGF have significantly poorer allograft survival. Optimizing the donor and recipient matching to avoid compounding risks may allow for better outcomes.
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Affiliation(s)
- Christine S Hwang
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Yash Kadakia
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jorge A Sanchez-Vivaldi
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Jigesh A Shah
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Lucia DeGregorio
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Dev M Desai
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Parsia A Vagefi
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
| | - Malcolm MacConmara
- Division of Surgical Transplantation, Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Transplantation, Children's Medical Center, Dallas, TX, USA
- TransMedics, Andover, MA, USA
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6
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Chen HF, Ali H, Marrero WJ, Parikh ND, Lavieri MS, Hutton DW. The Magnitude of the Health and Economic Impact of Increased Organ Donation on Patients With End-Stage Renal Disease. MDM Policy Pract 2021; 6:23814683211063418. [PMID: 34901442 PMCID: PMC8655828 DOI: 10.1177/23814683211063418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives. There are several approaches such as presumed consent and compensation for deceased donor organs that could reduce the gap between supply and demand for kidneys. Our objective is to evaluate the magnitude of the economic impact of policies to increase deceased donor organ donation in the United States. Methods. We built a Markov model and simulate an open cohort of end-stage renal disease patients awaiting kidney transplantation in the United States over 20 years. Model inputs were derived from the United States Renal Data System and published literature. We evaluate the magnitude of the health and economic impact of policies to increase deceased donor kidney donation in the United States. Results. Increasing deceased kidney donation by 5% would save $4.7 billion, and gain 30,870 quality-adjusted life years over the lifetime of an open cohort of patients on dialysis on the waitlist for kidney transplantation. With an increase in donations of 25%, the cost saved was $21 billion, and 145,136 quality-adjusted life years were gained. Policies increasing deceased kidney donation by 5% could pay donor estates $8000 or incur a onetime cost of up to $4 billion and still be cost-saving. Conclusions. Increasing deceased kidney donation could significantly impact national spending and health for end-stage renal disease patients.
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Affiliation(s)
- Huey-Fen Chen
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Hayatt Ali
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Wesley J Marrero
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Neehar D Parikh
- Department of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
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7
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Cheng XS, Held PJ, Dor A, Bragg-Gresham JL, Tan JC, Scandling JD, Chertow GM, Roberts JP. The organ procurement costs of expanding deceased donor organ acceptance criteria: Evidence from a cost function model. Am J Transplant 2021; 21:3694-3703. [PMID: 33884757 DOI: 10.1111/ajt.16617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/25/2021] [Accepted: 04/14/2021] [Indexed: 01/25/2023]
Abstract
A potential solution to the deceased donor organ shortage is to expand donor acceptability criteria. The procurement cost implications of using nonstandard donors is unknown. Using 5 years of US organ procurement organization (OPO) data, we built a cost function model to make cost projections: the total cost was the dependent variable; production outputs, including the number of donors and organs procured, were the independent variables. In the model, procuring one kidney or procuring both kidneys from double/en bloc transplantation from a single-organ donor resulted in a marginal cost of $55 k (95% confidence interval [CI] $28 k, $99 k) per kidney, and procuring only the liver from a single-organ donor results in a marginal cost of $41 k (95% CI $12 k, $69 k) per liver. Procuring two kidneys for two candidates from a donor lowered the marginal cost to $36 k (95% CI $22 k, $66 k) per kidney, and procuring two kidneys and a liver lowers the marginal cost to $24 k (95% CI $17 k, $45 k) per organ. Economies of scale were observed, where high OPO volume was correlated with lower costs. Despite higher cost per organ than for standard donors, kidney transplantation from nonstandard donors remained cost-effective based on contemporary US data.
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Affiliation(s)
- Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Philip J Held
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Avi Dor
- Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | | | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - John D Scandling
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Glenn M Chertow
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - John P Roberts
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California
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8
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Opatrný V, Třeška V, Zeithaml J, Hes O, Matějka R, Moláček J. Perfusion of a Kidney Graft from a Donor After Cardiac Death Based on Immediately Started Machine Perfusion: An Experimental Study on a Big Animal. Transplant Proc 2021; 53:2082-2090. [PMID: 34274120 DOI: 10.1016/j.transproceed.2021.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/13/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Donation after circulatory death donors are becoming a common source of organs for transplant. Despite good long-term outcomes of grafts from donation after circulatory death, this group is affected by a higher occurrence of delayed graft function and primary nonfunction. Our hypothesis is based on the assumption that washing the kidney grafts in the donor's body using a simple mechanical perfusion pump will result in faster and better perfusion of the parenchyma and more efficient cooling compared with hydrostatic perfusion alone. METHODS A total of 7 experimental animals (pigs) were used. The animals were divided into 2 groups: group A (n = 3) and group B (n = 4). After a 30-minute ischemic period for the selected kidney (clamped renal vessels), intra-arterial perfusion was performed. In group A perfusion was performed using hydrostatic pressure; in group B mechanical controlled perfusion was performed. After perfusion, declamping of the renal vessels caused restoration of flow. For graft quality evaluation, biopsy specimens were harvested, and the cooling speed was observed. Laboratory markers or renal failure were determined. RESULTS We found no significant differences between temperature drop and total diuresis between groups A and B. A significant difference was found between the groups in both flow parameters (flow maximum and mean flow) (P = .007, respectively P = .019). No laboratory parameters were found to be statistically significantly different. Histopathological analysis strongly supports the hypothesis of better flushing of kidney grafts using mechanical perfusion. CONCLUSIONS Based on our results, better kidney graft quality can be expected after immediately started mechanical perfusion in situ.
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Affiliation(s)
- Václav Opatrný
- Faculty of Medicine in Plzen, Department of Surgery, Charles University, University Hospital in Plzen, Plzen, Czech Republic; Faculty of Medicine in Plzen, Transplantcentrum, Charles University, University Hospital in Plzen, Plzen, Czech Republic
| | - Vladislav Třeška
- Faculty of Medicine in Plzen, Department of Surgery, Charles University, University Hospital in Plzen, Plzen, Czech Republic; Faculty of Medicine in Plzen, Transplantcentrum, Charles University, University Hospital in Plzen, Plzen, Czech Republic
| | - Jan Zeithaml
- Faculty of Medicine in Plzen, Department of Surgery, Charles University, University Hospital in Plzen, Plzen, Czech Republic
| | - Ondřej Hes
- Sikl's Institute of Pathological Anatomy, University Hospital in Plzen, Plzen, Czech Republic
| | - Roman Matějka
- Faculty of Biomedical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Jiří Moláček
- Faculty of Medicine in Plzen, Department of Surgery, Charles University, University Hospital in Plzen, Plzen, Czech Republic; Faculty of Medicine in Plzen, Transplantcentrum, Charles University, University Hospital in Plzen, Plzen, Czech Republic.
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9
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Legeai C, Durand L, Savoye E, Macher MA, Bastien O. Effect of preservation solutions for static cold storage on kidney transplantation outcomes: A National Registry Study. Am J Transplant 2020; 20:3426-3442. [PMID: 32400921 DOI: 10.1111/ajt.15995] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/25/2020] [Accepted: 04/22/2020] [Indexed: 01/25/2023]
Abstract
This study aimed to evaluate how 5 preservation solutions for static cold storage affected kidney transplant outcomes. It included all first single kidney transplants during 2010-2014 from donations after brain death in the French national transplant registry, excluding preemptive transplants and transplants of kidneys preserved with a hypothermic perfusion machine. The effects of each preservation solution on delayed graft function (DGF) and 1-year transplant failure were evaluated with hierarchical multivariable logistic regression models. The study finally included 7640 transplanted kidneys: 3473 (45.5%) preserved with Institut Georges Lopez-1 solution (IGL-1), 773 (10.1%) with University of Wisconsin solution, 731 (9.6%) with Solution de Conservation des Organes et Tissus (SCOT, organ and tissue preservation solution), 2215 (29.0%) with Celsior, and 448 (5.9%) with histidine-tryptophan-ketoglutarate. Primary nonfunction rates did not differ by solution. After adjustment for donor, recipient, and transplant characteristics, the DGF risk was significantly lower with IGL-1 than with all other solutions (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.48-0.64). Conversely, SCOT was associated with a DGF risk significantly higher than the other solutions (OR 2.69, 95% CI 2.21-3.27) and triple that of IGL-1 (OR 3.37, 95% CI 2.72-4.16). One year after transplantation, the transplant failure rate did not differ significantly by preservation solution. The difference between the groups for 1-year mean creatinine clearance was not clinically relevant.
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Affiliation(s)
- Camille Legeai
- Organ and Tissue Procurement and Transplantation Department, Agence de la Biomédecine, Saint Denis La Plaine, France
| | - Louise Durand
- Organ and Tissue Procurement and Transplantation Department, Agence de la Biomédecine, Saint Denis La Plaine, France
| | - Emilie Savoye
- Organ and Tissue Procurement and Transplantation Department, Agence de la Biomédecine, Saint Denis La Plaine, France
| | - Marie-Alice Macher
- Organ and Tissue Procurement and Transplantation Department, Agence de la Biomédecine, Saint Denis La Plaine, France
| | - Olivier Bastien
- Organ and Tissue Procurement and Transplantation Department, Agence de la Biomédecine, Saint Denis La Plaine, France
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10
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Cost-effectiveness of adrenaline for out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:579. [PMID: 32981529 PMCID: PMC7520962 DOI: 10.1186/s13054-020-03271-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/02/2020] [Indexed: 12/26/2022]
Abstract
Background The ‘Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration In Cardiac Arrest’ (PARAMEDIC2) trial showed that adrenaline improves overall survival, but not neurological outcomes. We sought to determine the within-trial and lifetime health and social care costs and benefits associated with adrenaline, including secondary benefits from organ donation. Methods We estimated the costs, benefits (quality-adjusted life years (QALYs)) and incremental cost-effectiveness ratios (ICERs) associated with adrenaline during the 6-month trial follow-up. Model-based analyses explored how results altered when the time horizon was extended beyond 6 months and the scope extended to include recipients of donated organs. Results The within-trial (6 months) and lifetime horizon economic evaluations focussed on the trial population produced ICERs of £1,693,003 (€1,946,953) and £81,070 (€93,231) per QALY gained in 2017 prices, respectively, reflecting significantly higher mean costs and only marginally higher mean QALYs in the adrenaline group. The probability that adrenaline is cost-effective was less than 1% across a range of cost-effectiveness thresholds. Combined direct economic effects over the lifetimes of survivors and indirect economic effects in organ recipients produced an ICER of £16,086 (€18,499) per QALY gained for adrenaline with the probability that adrenaline is cost-effective increasing to 90% at a £30,000 (€34,500) per QALY cost-effectiveness threshold. Conclusions Adrenaline was not cost-effective when only directly related costs and consequences are considered. However, incorporating the indirect economic effects associated with transplanted organs substantially alters cost-effectiveness, suggesting decision-makers should consider the complexity of direct and indirect economic impacts of adrenaline. Trial registration ISRCTN73485024. Registered on 13 March 2014.
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11
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Kim DW, Tsapepas D, King KL, Husain SA, Corvino FA, Dillon A, Wang W, Mayne TJ, Mohan S. Financial impact of delayed graft function in kidney transplantation. Clin Transplant 2020; 34:e14022. [PMID: 32573812 DOI: 10.1111/ctr.14022] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Abstract
Increased utilization of suboptimal organs in response to organ shortage has resulted in increased incidence of delayed graft function (DGF) after transplantation. Although presumed increased costs associated with DGF are a deterrent to the utilization of these organs, the financial burden of DGF has not been established. We used the Premier Healthcare Database to conduct a retrospective analysis of healthcare resource utilization and costs in kidney transplant patients (n = 12 097) between 1/1/2014 and 12/31/2018. We compared cost and hospital resource utilization for transplants in high-volume (n = 8715) vs low-volume hospitals (n = 3382), DGF (n = 3087) vs non-DGF (n = 9010), and recipients receiving 1 dialysis (n = 1485) vs multiple dialysis (n = 1602). High-volume hospitals costs were lower than low-volume hospitals ($103 946 vs $123 571, P < .0001). DGF was associated with approximately $18 000 (10%) increase in mean costs ($130 492 vs $112 598, P < .0001), 6 additional days of hospitalization (14.7 vs 8.7, P < .0001), and 2 additional ICU days (4.3 vs 2.1, P < .0001). Multiple dialysis sessions were associated with an additional $10 000 compared to those with only 1. In conclusion, DGF is associated with increased costs and length of stay for index kidney transplant hospitalizations and payment schemes taking this into account may reduce clinicians' reluctance to utilize less-than-ideal kidneys.
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Affiliation(s)
- Daniel W Kim
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Demetra Tsapepas
- Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA.,Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, NY, USA.,Department of Analytics, New York Presbyterian Hospital, New York, NY, USA
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | | | | | | | | | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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12
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Senanayake S, Graves N, Healy H, Baboolal K, Kularatna S. Cost-utility analysis in chronic kidney disease patients undergoing kidney transplant; what pays? A systematic review. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:18. [PMID: 32477010 PMCID: PMC7236510 DOI: 10.1186/s12962-020-00213-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/13/2020] [Indexed: 12/14/2022] Open
Abstract
Background Health systems are under pressure to deliver more effective care without expansion of resources. This is particularly pertinent to diseases like chronic kidney disease (CKD) that are exacting substantial financial burden to many health systems. The aim of this study is to systematically review the Cost Utility Analysis (CUA) evidence generated across interventions for CKD patients undergoing kidney transplant (KT). Methods A systemic review of CUA on the interventions for CKD patients undergoing KT was carried out using a search of the MEDLINE, CINAHL, EMBASE, PsycINFO and NHS-EED. The CHEERS checklist was used as a set of good practice criteria in determining the reporting quality of the economic evaluation. Quality of the data used to inform model parameters was determined using the modified hierarchies of data sources. Results A total of 330 articles identified, 16 met the inclusion criteria. Almost all (n = 15) the studies were from high income countries. Out of the 24 characteristics assessed in the CHEERS checklist, more than 80% of the selected studies reported 14 of the characteristics. Reporting of the CUA were characterized by lack of transparency of model assumptions, narrow economic perspective and incomplete assessment of the effect of uncertainty in the model parameters on the results. The data used for the economic model were satisfactory quality. The authors of 13 studies reported the intervention as cost saving and improving quality of life, whereas three studies were cost increasing and improving quality of life. In addition to the baseline analysis, sensitivity analysis was performed in all the evaluations except one. Transplanting certain high-risk donor kidneys (high risk of HIV and Hepatitis-C infected kidneys, HLA mismatched kidneys, high Kidney Donor Profile Index) and a payment to living donors, were found to be cost-effective. Conclusions The quality of economic evaluations reviewed in this paper were assessed to be satisfactory. Implementation of these strategies will significantly impact current systems of KT and require a systematic implementation plan and coordinated efforts from relevant stakeholders.
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Affiliation(s)
- Sameera Senanayake
- 1Australian Centre for Health Services Innovation, School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Brisbane, QLD 4059 Australia
| | - Nicholas Graves
- 1Australian Centre for Health Services Innovation, School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Brisbane, QLD 4059 Australia
| | - Helen Healy
- 2Royal Brisbane Hospital for Women, Brisbane, Australia.,3School of Medicine, University of Queensland, Brisbane, Australia
| | - Keshwar Baboolal
- 2Royal Brisbane Hospital for Women, Brisbane, Australia.,3School of Medicine, University of Queensland, Brisbane, Australia
| | - Sanjeewa Kularatna
- 1Australian Centre for Health Services Innovation, School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Brisbane, QLD 4059 Australia
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13
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Zens TJ, Danobeitia JS, Leverson G, Chlebeck PJ, Zitur LJ, Redfield RR, D'Alessandro AM, Odorico S, Kaufman DB, Fernandez LA. The impact of kidney donor profile index on delayed graft function and transplant outcomes: A single-center analysis. Clin Transplant 2019; 32:e13190. [PMID: 29314286 DOI: 10.1111/ctr.13190] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Renal transplant outcomes result from a combination of factors. Traditionally, donor factors were summarized by classifying kidneys as extended criteria or standard criteria. In 2014, the nomenclature changed to describe donor factors with the kidney donor profile index (KDPI). We aim to evaluate the relationship between KDPI and delayed graft function (DGF), and the impact KDPI on transplant outcomes for both donor after cardiac death (DCD) and donor after brain death (DBD). METHODS An IRB-approved single-center retrospective chart review was performed from January 1999 to July 2013. The patients were divided into six groups: DBD KDPI ≤60, DBD KPDI 61-84, DBD KDPI ≥85, DCD KDPI ≤60, DCD KPDI 61-84, and DCD KDPI ≥85. Rates of DGF, patient survival, and graft survival were examined among groups. RESULTS A total of 2161 kidney transplants were included. DGF rates increased, and graft and patient survival decreased with increasing KDPI (P < .001). DCD kidneys had higher DGF rates than their DBD counterparts (P < .001). In DCD kidneys, a higher KDPI score did not significantly affect the DGF rates (P > .302). There was no significant difference in graft or patient survival in all-comers when comparing DCD and DBD kidneys with equivalent KDPIs (P > .317). Patients with DGF across all categories demonstrated worse graft half-lives. CONCLUSION The KDPI system is an accurate predictor of donor contributions to transplant outcomes. Recipients of DBD kidneys experience an increase in the rate of DGF as their KDPI increases. DCD kidneys have higher DGF rates than their DBD counterparts with similar KDPIs. Patients with documented post-transplant DGF had between 3- and 5-year shorter graft half-lives when compared to recipients that did not experience DGF. Initiatives to reduce the rate of DGF could provide a significant impact on graft survival and result in a reduction in the number of patients requiring retransplant.
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Affiliation(s)
- Tiffany J Zens
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Juan S Danobeitia
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Glen Leverson
- Division of Statistics, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Peter J Chlebeck
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Laura J Zitur
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Anthony M D'Alessandro
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Scott Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Luis A Fernandez
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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14
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The Relationships Between Cold Ischemia Time, Kidney Transplant Length of Stay, and Transplant-related Costs. Transplantation 2019; 103:401-411. [DOI: 10.1097/tp.0000000000002309] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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A Cost-Effectiveness Analysis of Organ Preservation Methods for Deceased Donor Kidneys at High Risk for Delayed Graft Function in Brazil. Transplant Proc 2018; 50:3121-3127. [DOI: 10.1016/j.transproceed.2018.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 11/19/2022]
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16
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Shelton BA, Sawinski D, Linas BP, Reese PP, Mustian M, Hungerpiller M, Reed RD, MacLennan PA, Locke JE. Population level outcomes and cost-effectiveness of hepatitis C treatment pre- vs postkidney transplantation. Am J Transplant 2018; 18:2483-2495. [PMID: 30058218 PMCID: PMC6206868 DOI: 10.1111/ajt.15040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/03/2018] [Accepted: 07/23/2018] [Indexed: 01/25/2023]
Abstract
Direct-acting antivirals approved for use in patients with end-stage renal disease (ESRD) now exist. HCV-positive (HCV+) ESRD patients have the opportunity to decrease the waiting times for transplantation by accepting HCV-infected kidneys. The optimal timing for HCV treatment (pre- vs posttransplant) among kidney transplant candidates is unknown. Monte Carlo microsimulation of 100 000 candidates was used to examine the cost-effectiveness of HCV treatment pretransplant vs posttransplant by liver fibrosis stage and waiting time over a lifetime time horizon using 2 regimens approved for ESRD patients. Treatment pretransplant yielded higher quality-adjusted life years (QALYs) compared with posttransplant treatment in all subgroups except those with Meta-analysis of Histological Data in Viral Hepatitis stage F0 (pretransplant: 5.7 QALYs vs posttransplant: 5.8 QALYs). However, treatment posttransplant was cost-saving due to decreased dialysis duration with the use of HCV-infected kidneys (pretransplant: $735 700 vs posttransplant: $682 400). Using a willingness-to-pay threshold of $100 000, treatment pretransplant was not cost-effective except for those with Meta-analysis of Histological Data in Viral Hepatitis stage F3 whose fibrosis progression was halted. If HCV+ candidates had access to HCV-infected donors and were transplanted ≥9 months sooner than HCV-negative candidates, treatment pretransplant was no longer cost-effective (incremental cost-effectiveness ratio [ICER]: $107 100). In conclusion, optimal timing of treatment depends on fibrosis stage and access to HCV+ kidneys but generally favors posttransplant HCV eradication.
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Affiliation(s)
- Brittany A. Shelton
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Deirdre Sawinski
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Peter P. Reese
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Margaux Mustian
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Mitch Hungerpiller
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Rhiannon D. Reed
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Paul A. MacLennan
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Jayme E. Locke
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
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17
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Chitasombat MN, Watcharananan SP. Burden of cytomegalovirus reactivation post kidney transplant with antithymocyte globulin use in Thailand: A retrospective cohort study. F1000Res 2018; 7:1568. [PMID: 30473779 PMCID: PMC6234719 DOI: 10.12688/f1000research.16321.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Cytomegalovirus (CMV) is an important cause of infectious complications after kidney transplantation (KT), especially among patients receiving antithymocyte globulin (ATG). CMV infection can result in organ dysfunction and indirect effects such as graft rejection, graft failure, and opportunistic infections . Prevention of CMV reactivation includes pre-emptive or prophylactic approaches. Access to valganciclovir prophylaxis is limited by high cost. Our objective is to determine the burden and cost of treatment for CMV reactivation/disease among KT recipients who received ATG in Thailand since its first use in our center. Methods: We conducted a single-center retrospective cohort study of KT patients who received ATG during 2010-2013. We reviewed patients' characteristics, type of CMV prophylaxis, incidence of CMV reactivation, and outcome (co-infections, graft function and death). We compared the treatment cost between patients with and without CMV reactivation. Results: Thirty patients included in the study had CMV serostatus D+/R+. Twenty-nine patients received intravenous ganciclovir early after KT as inpatients. Only three received outpatient valganciclovir prophylaxis. Incidence of CMV reactivation was 43%, with a median onset of 91 (range 23-1007) days after KT. Three patients had CMV end-organ disease; enterocolitis or retinitis. Infectious complication rate among ATG-treated KT patients was up to 83%, with a trend toward a higher rate among those with CMV reactivation ( P = 0.087). Patients with CMV reactivation/disease required longer duration of hospitalization ( P = 0.018). The rate of graft loss was 17%. The survival rate was 97%. The cost of treatment among patients with CMV reactivation was significantly higher for both inpatient setting ( P = 0.021) and total cost ( P = 0.035) than in those without CMV reactivation. Conclusions: Burden of infectious complications among ATG-treated KT patients was high. CMV reactivation is common and associated with longer duration of hospitalization and higher cost.
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Affiliation(s)
- Maria N. Chitasombat
- Division of Infectious disease, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Siriorn P. Watcharananan
- Division of Infectious disease, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
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18
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Yunhua T, Qiang Z, Lipeng J, Shanzhou H, Zebin Z, Fei J, Zhiheng Z, Linhe W, Weiqiang J, Dongping W, Zhiyong G, Xiaoshun H. Liver Transplant Recipients With End-Stage Renal Disease Largely Benefit From Kidney Transplantation. Transplant Proc 2018; 50:202-210. [PMID: 29407310 DOI: 10.1016/j.transproceed.2017.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/11/2017] [Accepted: 11/03/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The incidence of end-stage renal disease (ESRD) after liver transplant (LT) has increased. The actual benefit of kidney transplantation (KT) is not completely understood in LT recipients with ESRD. METHODS We analyzed Scientific Registry of Transplant Recipients data for all KT candidates with prior LT from 1998 to 2014; the benefits of KT relative to remaining on dialysis were compared by means of multivariate Cox proportional hazards regression analysis. RESULTS The number of these KT candidates with prior LT has tripled from 98 in 1998 to 323 in 2015; LT recipients with ESRD remaining on dialysis have a 2.5-times increase in the risk of liver graft failure and a 3.6-times increase in the risk of patient death compared with these patients receiving KT. The adjusted liver graft and patient survival rates after donors from donation after cardiac death or expanded-criteria donor kidney transplantation were significantly higher than in patients remaining on dialysis in LT recipients with ESRD. CONCLUSIONS The number of referrals to KT with prior LT is increasing at a rapid rate. Remaining on dialysis in LT recipients with ESRD has profound increased risks of liver graft failure and patient death in comparison to receiving a KT. LT recipients with ESRD can benefit from expanded-criteria donor and donation after cardiac death kidney transplantation.
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Affiliation(s)
- T Yunhua
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Z Qiang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - J Lipeng
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - H Shanzhou
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Z Zebin
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - J Fei
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Z Zhiheng
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - W Linhe
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - J Weiqiang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - W Dongping
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - G Zhiyong
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China.
| | - H Xiaoshun
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China.
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19
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Chen Y, Tillman BW, Cho SK, Richards TD, Tevar AD, Gu X, Wagner WR, Chun Y. A novel compartmentalised stent graft to isolate the perfusion of the abdominal organs. J Med Eng Technol 2016; 41:141-150. [PMID: 27715350 DOI: 10.1080/03091902.2016.1239279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Donation after cardiac death has been adopted to address the critical shortage of donor organs for transplant. Recovery of these organs is hindered by low blood flow that leads to permanent organ injury. We propose a novel approach to isolate the perfusion of the abdominal organs from the systemic malperfusion of the dying donor. We reasoned that this design could improve blood flow to organs without open surgery, while respecting the ethical principle that cardiac stress not be increased during organ recovery. Conditions within the stent were analysed using a computational fluid dynamics (CFD) method and validated on two prototypes in vitro. The hydrodynamic pressure drop across the stent was measured as 0.14-0.22 mmHg, which is a negligible influence. Device placement studies were also conducted on swine model fluoroscopically. All these results demonstrated the feasibility of rapidly isolating the perfusion to abdominal organs using a compartmentalised stent graft design.
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Affiliation(s)
- Yanfei Chen
- a Department of Industrial Engineering , University of Pittsburgh , Pittsburgh , PA , USA
| | - Bryan W Tillman
- b Division of Vascular Surgery , University of Pittsburgh Medical Centre , Pittsburgh , PA , USA.,c Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA.,d McGowan Institute for Regenerative Medicine, University of Pittsburgh , Pittsburgh , PA , USA
| | - Sung Kwon Cho
- e Department of Mechanical Engineering and Materials Science , University of Pittsburgh , Pittsburgh, Pittsburgh , PA , USA
| | - Tara D Richards
- c Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA
| | - Amit D Tevar
- c Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA.,f Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Centre , Pittsburgh , PA , USA
| | - Xinzhu Gu
- d McGowan Institute for Regenerative Medicine, University of Pittsburgh , Pittsburgh , PA , USA
| | - William R Wagner
- c Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA.,d McGowan Institute for Regenerative Medicine, University of Pittsburgh , Pittsburgh , PA , USA.,g Department of Bioengineering , University of Pittsburgh , Pittsburgh , PA , USA.,h Department of Chemical and Petroleum Engineering , University of Pittsburgh , Pittsburgh , PA , USA
| | - Youngjae Chun
- a Department of Industrial Engineering , University of Pittsburgh , Pittsburgh , PA , USA.,d McGowan Institute for Regenerative Medicine, University of Pittsburgh , Pittsburgh , PA , USA.,g Department of Bioengineering , University of Pittsburgh , Pittsburgh , PA , USA
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20
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Love KM, Brown JB, Harbrecht BG, Muldoon SB, Miller KR, Benns MV, Smith JW, Baker CE, Franklin GA. Organ donation as an outcome of traumatic cardiopulmonary arrest: A cost evaluation. J Trauma Acute Care Surg 2016; 80:792-8. [PMID: 26881486 DOI: 10.1097/ta.0000000000000984] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Survival after traumatic cardiopulmonary arrest (TCPA) is rare and requires significant resource expenditure. Organ donation as an outcome of TCPA resuscitation has not yet been included in a cost analysis. The aims of this study were to identify variables associated with survival and organ donation after TCPA, and to estimate the cost of achieving these outcomes. We hypothesized that the inclusion of organ donation as a potential outcome would make TCPA resuscitation more cost-effective. METHODS Adult patients who required resuscitation for TCPA at a level I trauma center were retrospectively reviewed over 36 months. Data were obtained from medical records, hospital accounting records, and the local organ procurement agency. Outcomes included survival to discharge, neurologic function, and organ donor eligibility. An individual-level state-transition cost-effectiveness model was used to evaluate the cost of TCPA resuscitation with and without organ donation included as an outcome. Incremental cost-effectiveness ratio was calculated to determine additional cost per life saved when organ donation is included. RESULTS Over the study period, 8,932 subjects were evaluated. Traumatic cardiopulmonary arrest occurred in 237 patients (3%). The mortality rate was 97%. Variables associated with survival included emergency department disposition to the operating room (p < 0.01) and reactive pupils (p < 0.001). Of seven survivors, four were discharged neurologically intact. Of the patients with TCPA, 5% were eligible for organ donation with a procurement rate of 2%. Organ donor eligibility was associated with arrest after arrival to the emergency department (p < 0.01) and transfusion of fresh frozen plasma (p = 0.01). The cost of TCPA resuscitation per survivor was $1.8 million; cost per survivor or life saved by donation was $538,000. The incremental cost-effectiveness ratio was $76,816 per additional life saved including donation as an outcome. CONCLUSION The decision to pursue resuscitation should continue to be based on the presence of signs of life, especially pupil reactivity and duration of arrest. If the primary objective is survival, organ procurement will be maximized without conflict of interest. Early fresh frozen plasma transfusion may increase successful organ donation. The financial burden of TCPA resuscitation can be mitigated by expanding end points to include organ donation. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III; cost analysis, level V.
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Affiliation(s)
- Katie M Love
- From the Department of Surgery (K.M.L., C.C.B.), Virginia Tech Carilion School of Medicine, Roanoke, VA; Department of Surgery (K.M.L., B.G.H., K.R.M., M.V.B., J.W.S., G.A.F.), University of Louisville School of Medicine, Louisville, KY; Department of Surgery (J.B.B.), University of Pittsburgh, Pittsburgh, PA; University of Louisville School of Public Health and Information Sciences (K.M.L., S.B.M.)
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Tillman BW, Chun Y, Cho SK, Chen Y, Liang N, Maul T, Demetris A, Gu X, Wagner WR, Tevar AD. Dual chamber stent prevents organ malperfusion in a model of donation after cardiac death. Surgery 2016; 160:892-901. [PMID: 27524434 DOI: 10.1016/j.surg.2016.06.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/16/2016] [Accepted: 06/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The paradigm for donation after cardiac death subjects donor organs to ischemic injury. A dual-chamber organ perfusion stent would maintain organ perfusion without affecting natural cardiac death. A center lumen allows uninterrupted cardiac blood flow, while an external chamber delivers oxygenated blood to the visceral vessels. METHODS A prototype organ perfusion stent was constructed from commercial stents. In a porcine model, the organ perfusion stent was deployed, followed by a simulated agonal period. Oxygenated blood perfused the external stent chamber. Organ perfusion was compared between controls (n = 3) and organ perfusion stent (n = 6). Finally, a custom, nitinol, dual chamber organ perfusion stent was fabricated using a retrievable "petal and stem" design. RESULTS Endovascular organ perfusion stent deployment achieved visceral isolation without adverse impact on cardiac parameters. Visceral oxygen delivery was 4.8-fold greater compared with controls. During the agonal period, organs in organ perfusion stent-treated animals appeared well perfused in contrast with the malperfused controls. A custom nitinol and polyurethane organ perfusion stent was recaptured easily with simple sheath advancement. CONCLUSION An organ perfusion stent maintained organ perfusion during the agonal phase in a porcine model of donation after cardiac death organ donation without adversely affecting cardiac function. Ultimately, the custom retrievable design of this study may help resolve the critical shortage of donor organs for transplant.
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Affiliation(s)
- Bryan W Tillman
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Youngjae Chun
- Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Sung Kwon Cho
- Mechanical Engineering & Materials Science, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Yanfei Chen
- Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Nathan Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Timothy Maul
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony Demetris
- Division of Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Xinzhu Gu
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - William R Wagner
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amit D Tevar
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
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Marlais M, Callaghan C, Marks SD. Kidney donation after circulatory death: current evidence and opportunities for pediatric recipients. Pediatr Nephrol 2016; 31:1039-45. [PMID: 26384332 DOI: 10.1007/s00467-015-3175-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/06/2015] [Accepted: 07/15/2015] [Indexed: 11/26/2022]
Abstract
Organ donation after circulatory death (DCD) has experienced a revival worldwide over the past 20 years, and is now widely practiced for kidney transplantation. Some previous concerns about these organs such as the high incidence of delayed graft function have been alleviated through evidence from adult studies. There are now a number of large adult cohorts reporting favorable 5-year outcomes for DCD kidney transplants, comparable to kidneys donated after brain death (DBD). This has resulted in a marked increase in the use of DCD kidneys for adult recipients in some countries and an increase in the overall number of kidney transplants. In contrast, the uptake of DCD kidneys for pediatric recipients is still low and concerns still exist over the longer-term outcomes of DCD organs. In view of the data from adult practice and the poor outcomes for children who stay on dialysis, DCD kidney transplantation should be offered as an option for children on the kidney transplant waiting list.
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Affiliation(s)
- Matko Marlais
- Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
| | - Stephen D Marks
- Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK.
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Évaluation médico-économique des stratégies de prise en charge de l’insuffisance rénale chronique terminale en France. Nephrol Ther 2016; 12:104-15. [DOI: 10.1016/j.nephro.2015.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 11/20/2022]
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Sánchez-Escuredo A, Diekmann F, Revuelta I, Esforzado N, Ricart MJ, Cofán F, Torregrosa JV, Peri L, Ruiz Á, Campistol JM, Oppenheimer F. An mTOR-inhibitor-based protocol and calcineurin inhibitor (CNI)-free treatment in kidney transplant recipients from donors after cardiac death: good renal function, but high incidence of conversion to CNI. Transpl Int 2016; 29:362-8. [DOI: 10.1111/tri.12732] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 08/03/2015] [Accepted: 08/09/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Ana Sánchez-Escuredo
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Fritz Diekmann
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Ignacio Revuelta
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Nuria Esforzado
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Maria Jose Ricart
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Frederic Cofán
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Jose-Vicente Torregrosa
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Lluis Peri
- Urology Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Ángel Ruiz
- Donation and Transplant Coordination Unit; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Josep Maria Campistol
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Federico Oppenheimer
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
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Abstract
BACKGROUND Bending the cost curve in medical expenses is a high national priority. The relationship between cost and kidney allograft failure has not been fully investigated in the United States. METHODS Using Medicare claims from the United States Renal Data System, we determined costs for all adults with Medicare coverage who underwent kidney transplant January 1, 2007, to June 30, 2009. We compared relative cost (observed/expected payment) for year 1 after transplantation for all transplant centers, adjusting for recipient, donor, and transplant characteristics, region, and local wage index. Using program-specific reports from the Scientific Registry of Transplant Recipients, we correlated relative cost with observed/expected allograft failure between centers, excluding small centers. RESULTS Among 19,603 transplants at 166 centers, mean observed cost per patient per center was $65,366 (interquartile range, $55,094-$71,624). Mean relative cost was 0.99 (± 0.20); mean observed/expected allograft failure was 1.03 (± 0.46). Overall, there was no correlation between relative cost and observed/expected allograft failure (r = 0.096, P = 0.22). Comparing centers with higher than expected costs and allograft failure rates (lower performing) and centers with lower than expected costs and failure rates (higher-performing) showed differences in donor and recipient characteristics. As these characteristics were accounted for in the adjusted cost and allograft failure models, they are unlikely to explain the differences between higher- and lower-performing centers. CONCLUSIONS Further investigations are needed to determine specific cost-effective practices of higher- and lower-performing centers to reduce costs and incidence of allograft failure.
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Cavallo MC, Sepe V, Conte F, Abelli M, Ticozzelli E, Bottazzi A, Geraci PM. Cost-effectiveness of kidney transplantation from DCD in Italy. Transplant Proc 2015; 46:3289-96. [PMID: 25498039 DOI: 10.1016/j.transproceed.2014.09.146] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 09/11/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Kidney transplantation represents the best therapeutic option for patients with end-stage renal disease (ESRD), providing the best outcomes for survival, quality of life, and cost-effectiveness. To increase kidney donations, in 2007, the Italian IRCCS Policlinico San Matteo Foundation in Pavia designed and conducted Programma Alba, a protocol for organ donation after cardiac death (DCD). This study evaluated the costs and health outcomes of DCD transplantation and in all types of transplants compared with current clinical practice. PATIENTS AND METHODS A Markov-based model was used to assess costs and health outcomes for new ESRD patients for 2008 to 2013. A health care founder perspective was used. Data sources were the Italian National Institute of Statistics and the Lombardy Registry of Dialysis and Transplantation. A microcosting analysis was performed to calculate costs related to clinical pathways for DCD. We assessed costs, survival, quality-adjusted survival, and cost-effectiveness. FINDINGS Changing the actual practice pattern for new patients with ESRD and increasing the availability of kidneys from DCD to 10 extra transplants per year will induce an incremental cost per quality-adjusted life-year of €4255. Increases in transplantation to reach an extra 10% by transplant type would result in reduced costs and increased patient survival and quality of life compared with the current scenario. INTERPRETATION Our data show that increasing DCD transplants would result in a cost-effective policy to expand the kidney donor pool compared with current ESRD treatment patterns. Italian policies should make an effort to increase transplant rates to optimize cost-effectiveness in ESRD service supply.
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Affiliation(s)
- M C Cavallo
- CeRGAS, Università Commerciale Luigi Bocconi, Milan, Italy
| | - V Sepe
- Unit of Nephrology, Dialysis, Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - F Conte
- Unit of Nephrology and Dialysis, Ospedale di Cernusco sul Naviglio, Cernusco sul Naviglio, Italy
| | - M Abelli
- Unit of Transplantation Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - E Ticozzelli
- Unit of Transplantation Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - A Bottazzi
- Intensive Care Unit 2, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - P M Geraci
- Transplantation Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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