Abstract
ObjectivesLiving donor kidney transplantation (LTx) is the preferred treatment for patients with end-stage renal disease. Kidney exchange programs (KEPs) promote LTx by facilitating exchange of donors among patients who are not compatible with their donors. We analyze and maximize the efficacy and effectiveness of KEPS from a health value perspective and the health value of altruistic donation in KEPs. MethodsWe developed a Markov model for the health outcomes of patients, which was embedded in a discrete event simulation model to assess the effectiveness of allocation policies in KEPs. A new allocation policy to maximize health value was developed on the basis of integer programing techniques. The evidence-based transition probabilities in the Markov model were based on data from the Dutch KEP using a variety of econometric models. Scenarios analysis was presented to improve robustness. ResultsThe efficacy of the Dutch KEP without altruistic donation is reflected by the increase in expected discounted quality-adjusted life-years (QALYs) by 3.23 from 6.42 to 9.65. The present Dutch policy and the policy to maximize the number of transplants achieve 63% of the potential efficacy gain (2.11 discounted QALYs). The new policy achieves 69% of this gain (2.33 discounted QALYs). When systematically enrolling altruistic donors in the KEP, the new policy increased expected discounted QALYs by 4.05 to 10.27 and reduced inequities for patients with blood type O. ConclusionsThe Dutch KEP can increase health value for patients by more than half. An allocation policy that maximizes health outcomes and maximally allows altruistic donation can yield significant further improvements.
Highlights
The burden of disease attributed to chronic kidney disease has almost doubled since 1990, forming 1.64% of the global burden of disease in 2019.1 Chronic kidney disease may progress over several stages toward end-stage renal disease (ESRD) and is the 11th most common cause of death globally.[1]
We extend this research toward the analysis of Kidney exchange programs (KEPs) effectiveness and develop a Markov model for health state transitions of patients with ESRD participating in a KEP
Given that the discounted qualityadjusted life-years (QALYs) for recipients who remain unmatched in the perfect KEP are higher than without KEP, the perfect KEP prioritizes patients who would otherwise have less than average remaining discounted QALYs
Summary
The burden of disease attributed to chronic kidney disease has almost doubled since 1990, forming 1.64% of the global burden of disease in 2019.1 Chronic kidney disease may progress over several stages toward end-stage renal disease (ESRD) and is the 11th most common cause of death globally.[1] An estimated 2.5 million patients were treated for ESRD worldwide in 2017, and an even larger number of patients lacked access to treatment.[2]. The most common treatment for ESRD is dialysis. The alternative of deceased donor transplantation (DTx) refers to the practice of harvesting organs for transplantation from deceased donors. The practice of transplanting 1 of the 2 kidneys from a living donor (LTx) has developed as a third alternative. The average total healthcare cost after transplant amounted V85.127 in the first year after transplant and V29 612 and V20 156 in the second and third years, respectively.[9]
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