Cost–utility analysis of living‐donor kidney transplantation followed by pancreas transplantation versus simultaneous pancreas–kidney transplantation

Abstract

For a type I diabetic with end-stage renal disease, the choice between a kidney-alone transplant from a living-donor (KA-LD) and a simultaneous pancreas kidney (SPK) transplant remains a difficult one. The prevailing practice seems to favor KA-LD over SPK, presumably due to the superior long-term renal graft survival in KA-LD and the elimination of the lengthy waiting time on the cadaver transplant list. In this study, two treatment options, KA-LD followed by pancreas-after-kidney (PAK) and SPK transplant, are compared using a cost-utility decision analysis model. The decision tree consisted of a choice between KA-LD + PAK and SPK. The analysis was based on a 5-yr model and the measures of outcome used in the model were cost, utility and cost-utility. The expected 5-yr cost was $277,638 for KA-LD + PAK and $288,466 for SPK. When adjusted for utilities, KA-LD + PAK at a cost of $153,911 was less cost-effective than SPK at a cost of $110,828 per quality-adjusted year. One-way sensitivity analyses were performed by varying patient and graft survival probabilities, utilities and cost. SPK remained the optimal strategy over KA-LD + PAK across all variations. Two-way sensitivity analysis showed that in order for KA-LD + PAK to be at least as cost-effective as SPK, 5-yr pancreas and patient survival rates following PAK would need to surpass 86 and 80%. In conclusion, according to the 5-yr cost-utility model presented in this study, KA-LD followed by PAK is less cost-effective than SPK as a treatment strategy for a type I diabetic with end-stage renal disease. For patients interested in the benefits of a pancreas transplant, it would be reasonable to offer SPK as the optimal treatment, even if a living kidney donor is available.

Kidney Allograft and Patient Survival in Type I Diabetic Recipients of Cadaveric Kidney Alone Versus Simultaneous Pancreas/Kidney Transplants

“…We controlled for center effects; therefore, we felt that variations in transplant management were unlikely to be relevant to our analysis. Finally, other factors that were not considered in this study are also important in assessing solid organ transplant outcome, patient survival, cost, quality of life, and morbidity from cardiovascular and peripheral vascular diseases (4,17,18).…”

Pancreatic and islet transplantation

“…The potential benefits of pancreas transplantation come with a cost of increased morbidity related to surgery and immunosuppression, and possibly with an additional financial burden on the healthcare system [82]. Moreover, as discussed by Purrello and Pipeleers [83], almost 50% of successfully transplanted patients exhibit impaired tolerance curves [84][85][86], raising questions about their protection against the long-term complications of chronic hyperglycemia.…”

Value Analysis of the Costliest Elective Lifesaving Procedures at an Academic Medical Center

“…The projected 5-year cost was $277,638 for KA-LD + PAK and $288,466 for SPK. The cost per QALY was $153,911 for KA-LD + PAK and $110,828 for SPK [17]. Therefore, KA-LD followed by PAK was less cost-effective than SPK as a treatment strategy for a type I diabetic with end-stage renal disease.…”