ACTIONS FOR POLICY AND IMPLEMENTATION

In the context of limited health care budgets and increasing demand for more funds for renal care, healthcare policy makers and planners have an opportunity to nudge the health system further towards kidney transplantation through reducing the discard rates of low-quality kidneys and reimbursement mechanisms that neutralise the short-term financial disincentives inherent in transplanting low-quality kidneys.

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Dr Sameera Senanayake

Research Fellow (Health economics), Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology

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RESEARCH CONTEXT

Compared to available renal replacement therapies, renal transplantation has dramatically improved the quality of life and the survival of patients with end-stage renal disease.  However, health systems around the world have not been able to meet the growing demand for kidney grafts. This is evident from the rising numbers of patients awaiting donor kidneys around the world.  To meet the growing demand for kidney transplantation, and to address the short supply of well-matched kidneys, the suitability criteria for deceased donors has been expanded. It is expected that this will increase the use of low-quality kidneys and decrease the discard rates.  However, as low-quality kidney transplants are associated with higher rates of graft loss and primary renal allograft dysfunction, they cost more than a regular transplant. Therefore, due to the greater likelihood of short-term costs associated with low-quality kidney transplants, health systems around the world are reluctant to increase those transplants due to an assumption that they may threaten the overall economic viability of transplant programs. 

Lack of evidence on the long-term cost-effectiveness of transplanting low-quality kidneys, compared to remaining on dialysis, hinders informed decision making by kidney transplant stakeholders. Furthermore, this leads to a dilemma for both patients and clinicians of whether to accept a kidney with a shorter graft survival projection (low quality kidney) or to allow the patient to remain on dialysis, knowing their mortality risk, while waiting for the next offer.

Models were developed and used to estimate cost-effectiveness from a healthcare payer’s perspective. Results indicated that transplanting a kidney of any quality was the most cost-effective treatment pathway for patients with end-stage kidney disease compared to staying on a waitlist and continuing dialysis. Transplanting higher-quality kidneys to younger patients and lower-quality kidneys to older patients returned the highest net monetary benefit. Continuing dialysis until a high-quality kidney became available was not a cost-effective strategy when compared to transplanting a lower-quality kidney without waiting. This is true for any age category.

It is important to demonstrate the value of transplanting low-quality kidneys to ensure that health systems move toward this type of transplant.  This study demonstrated that low-quality kidney transplants provide significant economic benefit to health systems as well as improvement in patient quality of life in the long run.

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