title: Efficacy, outcomes, and cost-effectiveness of desensitization using IVIG and rituximab.
abstract: BACKGROUND
  Transplantation rates are very low for the broadly sensitized patient (panel reactive antibody [PRA]>80%; HS). Here, we examine the efficacy, outcomes, and cost-effectiveness of desensitization using high-dose intravenous immunoglobulin (IVIG) and rituximab to improve transplantation rates in HS patients.
  
  
  METHODS
  From July 2006 to December 2011, 207 HS (56 living donors/151 deceased donors) patients (donor-specific antibody positive, PRA>80%) were desensitized using IVIG and rituximab. After desensitization, responsive patients proceeded to transplantation with an acceptable crossmatch. Cost and outcomes of desensitization were compared with dialysis.
  
  
  RESULTS
  Of the 207 treated patients, 146 (71%) were transplanted. At 48 months, patient and graft survival by Kaplan-Meier were 95% and 87.5%, respectively. The total 3-year cost for patients treated in the desensitization arm was $219,914 per patient compared with $238,667 per patient treated in the dialysis arm. Thus, each patient treated with desensitization is estimated to save the U.S. healthcare system $18,753 in 2011 USD. Overall, estimated patient survival at the end of 3 years was 96.6% for patients in the desensitization arm of the model (based on Cedars-Sinai survival rate) compared with 79.0% for an age, end-stage renal disease etiology, and PRA matched group of patients remaining on dialysis during the study period.
  
  
  CONCLUSIONS
  We conclude that desensitization with IVIG+rituximab is clinically and cost-effective, with both financial savings and an estimated 17.6% greater probability of 3-year survival associated with desensitization versus dialysis alone. However, the benefits of desensitization and transplantation are limited by organ availability and allocation policies.
authors.affiliation: Comprehensive Transplant Center, Cedars-Sinai Medical Center, 8635 West 3rd Street, Los Angeles, CA 90048, USA. Ashley.Vo@cshs.org
authors.forename: Ashley A
authors.initials: AA
authors.lastname: Vo
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Petrozzino
authors.forename: Kai
authors.initials: K
authors.lastname: Yeung
authors.forename: Aditi
authors.initials: A
authors.lastname: Sinha
authors.forename: Joseph
authors.initials: J
authors.lastname: Kahwaji
authors.forename: Alice
authors.initials: A
authors.lastname: Peng
authors.forename: Rafael
authors.initials: R
authors.lastname: Villicana
authors.forename: John
authors.initials: J
authors.lastname: Mackowiak
authors.forename: Stanley C
authors.initials: SC
authors.lastname: Jordan
mesh_terms: D000368:Aged; D000906:Antibodies / Q000378:metabolism; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003888:Desensitization, Immunologic / Q000191:economics* / Q000379:methods*; D005260:Female; D006085:Graft Survival; D017048:Health Care Costs; D006650:Histocompatibility Testing; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D007676:Kidney Failure, Chronic / Q000628:therapy*; D016030:Kidney Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D000069283:Rituximab; D016896:Treatment Outcome
chemical_list: D000906:Antibodies; D058846:Antibodies, Monoclonal, Murine-Derived; D016756:Immunoglobulins, Intravenous; D000069283:Rituximab