Kidney transplantation in the elderly: a decision analysis.
Transplantation offers superior life expectancy and quality of life compared with dialysis in young patients with end-stage renal failure. However, the initial risks of mortality and morbidity are high. This study used a decision analysis model to evaluate the costs and benefits of kidney transplantation versus continued dialysis for older patients with renal failure. A decision analytic model comparing cadaveric renal transplantation to continued hemodialysis treatment was developed. The base case considered a theoretical cohort of patients aged 65 yr without known comorbidity or contraindications to transplantation who would have to wait 2 yr for a cadaveric transplant. Separate models were constructed for patients with diabetes or cardiovascular disease and for patients receiving an organ after a variety of wait-list times. Probability, utility, and survival data were obtained from published reports and renal registries. For 65-yr-old patients, quality-adjusted life expectancy increased by 1.1 quality-adjusted life years (QALY) at an incremental cost of $67,778 per QALY. Assuming a 2-yr wait-listed time, transplantation remained economically attractive for 70-yr-old patients (incremental cost effectiveness [ICE], $79,359 per QALY) but was less economically attractive for those over 75 yr of age (ICE, $99,553) or for 70-yr-olds with either cardiovascular disease or diabetes (ICE, $126,751 and $161,090 per QALY, respectively). The analytic results were sensitive only to the time spent waiting for the graft. The cost-effectiveness reduced such that the costs associated with one QALY were in excess of $100,000/yr when the probability of a complication was > or = 50% per 3-mo cycle and when the utility of transplantation fell below 0.62. If available within a timely period, transplantation may offer substantial clinical benefits to older patients at a reasonable financial cost. Prolonged waiting times dramatically decrease the clinical benefits and economic attractiveness of transplantation, suggesting that living donor transplantation may be of particular benefit in this population.
Jassal
Sarbjit V
SV
Division of Nephrology, University Health Network, Toronto, Ontario, Canada. vanita.jassal@uhn.on.ca
Krahn
Murray D
MD
Naglie
Gary
G
Zaltzman
Jeffrey S
JS
Roscoe
Janet M
JM
Cole
Edward H
EH
Redelmeier
Donald A
DA
D000368:Aged; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D017048:Health Care Costs; D006801:Humans; D016030:Kidney Transplantation / Q000191:economics; D008017:Life Expectancy; D011788:Quality of Life; D006435:Renal Dialysis; D013997:Time Factors; D014850:Waiting Lists