Abstract 12624: Optimal Patient Selection for Simultaneous Heart-Kidney Transplant: A Modified Cost-Effectiveness Analysis

Abstract

Introduction: Increasing rates of simultaneous heart-kidney (SHK) transplant in the United States exacerbate the shortage of deceased donor kidneys (DDK) for kidney-only transplant (KT-only) candidates. Current allocation policy imposes no constraints on eligibility for SHK, and how best to do so remains unknown. Methods: We apply a decision analytic model to evaluate options for heart transplant (HT) candidates with comorbid kidney dysfunction, comparing 1) upfront SHK transplant (using a DDK) and 2) a “Safety Net” strategy, in which HT-only is performed first and DDK transplant is performed six months later if native kidneys do not recover. We measure “cost” in expected number of DDKs allocated to HT recipients, effectiveness in quality-adjusted life years (QALYs), and cost-effectiveness in terms of QALYs gained per kidney. We evaluate each outcome for patients of varying “reversibility”, defined as their probability of native kidney recovery after HT-only. We identify those for whom SHK (compared to Safety Net) is efficient from a societal standpoint, producing more QALYs per kidney than each additional kidney used for KT-only. Results: For a candidate with 50% reversibility, SHK (compared to Safety Net) produces 0.54 - 0.77 more QALYs (varying by age) at a cost of 0.58 more kidneys used. SHK is inefficient in this scenario, producing fewer QALYs per DDK (0.92 - 1.31) than an additional DDK allocated for KT-only (2.2 QALYs per kidney, derived from published estimates). SHK confers more benefit and is more cost-effective with decreasing age and reversibility, and is preferred to Safety Net for patients with reversibility under 24 - 38%. Conclusions: A Safety Net strategy produces greater societal benefit than SHK for HT candidates with concurrent kidney dysfunction, excepting only those with a low probability of native kidney recovery. This finding favors implementation of a Safety Net provision and should inform the use of objective criteria to limit SHK eligibility.