Kidney transplantation is the optimal therapy for end-stage renal disease, prolonging survival and reducing spending. Prior economic analyses of kidney transplantation, using Markov models, have generally assumed compatible, low-risk donors. The economic implications of transplantation with high Kidney Donor Profile Index (KDPI) deceased donors, ABO incompatible living donors, and HLA incompatible living donors have not been assessed. The costs of transplantation and dialysis were compared with the use of discrete event simulation over a 10-year period, with data from the United States Renal Data System, University HealthSystem Consortium, and literature review. Graft failure rates and expenditures were adjusted for donor characteristics. All transplantation options were associated with improved survival compared with dialysis (transplantation: 5.20-6.34 quality-adjusted life-years [QALYs] vs dialysis: 4.03 QALYs). Living donor and low-KDPI deceased donor transplantations were cost-saving compared with dialysis, while transplantations using high-KDPI deceased donor, ABO-incompatible or HLA-incompatible living donors were cost-effective (<$100 000 per QALY). Predicted costs per QALY range from $39 939 for HLA-compatible living donor transplantation to $80 486 for HLA-incompatible donors compared with $72 476 for dialysis. In conclusion, kidney transplantation is cost-effective across all donor types despite higher costs for marginal organs and innovative living donor practices.

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Previous economic analyses of liver transplantation have focused on the cost of the transplant and subsequent care. Accurate characterization of the pretransplant costs, indexed to severity of illness, is needed to assess the economic burden of liver disease. A novel data set linking Medicare claims with transplant registry data for 15 710 liver transplant recipients was used to determine average monthly waitlist spending (N ¼ 249 434 waitlist months) using multivariable linear regression models to adjust for recipient characteristics including Model for End-Stage Liver Disease (MELD) score. Characteristics associated with higher spending included older age, female gender, hepatocellular carcinoma, diabetes, hypertension and increasing MELD score (p < 0.05 for all). Spending increased exponentially with severity of illness: expected monthly spending at a MELD score of 30 was 10 times higher than at MELD of 20 ($22 685 vs. $2030). Monthly spending within MELD strata also varied geographically. For candidates with a MELD score of 35, spending varied from $19 548 (region 10) to $36 099 (region 7). Regional variation in waitlist costs may reflect the impact of longer waiting times on greater pretransplant hospitalization rates among high MELD score patients. Reducing the number of high MELD waitlist patients through improved medical management and novel organ allocation systems could decrease total spending for end-stage liver care.

chemo-radio-therapy with intralesional surgical resection and the use of MTP-PE as bio-therapy. While having no direct effect on osteosarcoma, MTP-PE is encapsulated into liposomes for direct delivery into pulmonary macrophages and monocytes. There, it stimulates these cells to become tumoricidal by promoting inflammatory cell infiltration and tumor cell loss, both alone, and in conjunction with more traditional chemotherapy agents [13,14].There were several unique aspects to the management strategy of this patient. It required close collaboration among pediatric and radiation oncologists, and pediatric, orthopedic and neurosurgeons. The interdisciplinary treatment adopted was greatly aided by the construction of the stereolithographic model, which served as a concrete focus for all participants during the planning of the surgical procedure and radiation therapy. While the use of models has been commonplace among dentists and oral surgeons for many years, it has only recently been used for complex craniofacial and neurosurgical procedures [15,16]. To date, there has been only one report of the use of modeling in the spine [17]. Combined anterior and posterior operations for spinal tumors are well described, and instrumentation in a fusion is common, but the use of stabilizing cross-linking from front-to-back has not been described. Similarly, brachytherapy and external beam irradiation are not part of conventional therapy for osteosarcoma.Five year disease-free survival after incompletely resected osteosarcoma is rare and in this case resulted from multi-modal therapy facilitated by a high degree of collaboration among pediatric specialists. Clearly, our patient suffered a number of secondary problems due to the aggressive approach to therapy. However, given the especially poor prognosis of spinal osteosarcoma in general, her disease-free survival to date is a credit to a multidisciplinary approach to management. Until more advances are made in the care of patients with unresectable tumors like this, innovative approaches such as we describe may be enlisted in hopes of extending survival for patients with particularly challenging clinical problems.