Cost-effectiveness of Using Kidneys From HCV-Viremic Donors for Transplantation Into HCV-Uninfected Recipients

Am J Kidney Dis. 2020 Jun;75(6):857-867. doi: 10.1053/j.ajkd.2019.11.005. Epub 2020 Feb 17.

Abstract

Rationale & objective: Less than 4% of patients with kidney failure receive kidney transplants. Although discard rates of hepatitis C virus (HCV)-viremic kidneys are declining, ~39% of HCV-viremic kidneys donated between 2018 and 2019 were discarded. Highly effective antiviral agents are now available to treat chronic HCV infection. Thus, our objective was to examine the cost-effectiveness of transplanting kidneys from HCV-viremic donors into HCV-uninfected recipients.

Study design: Markov state transition decision model. Data sources include Medline search results, bibliographies from relevant English language articles, Scientific Registry of Transplant Recipients, and the US Renal Data System.

Setting & population: US patients receiving maintenance hemodialysis who are on kidney transplant waiting lists.

Intervention(s): Transplantation with an HCV-unexposed kidney versus transplantation with an HCV-viremic kidney and HCV treatment.

Outcomes: Effectiveness measured in quality-adjusted life-years and costs measured in 2018 US dollars.

Model, perspective, and timeframe: We used a health care system perspective with a lifelong time horizon.

Results: In the base-case analysis, transplantation with an HCV-viremic kidney was more effective and less costly than transplantation with an HCV-unexposed kidney because of the longer waiting times for HCV-unexposed kidneys, the substantial excess mortality risk while receiving dialysis, and the high efficacy of direct-acting antiviral agents for HCV infection. Transplantation with an HCV-viremic kidney was also preferred in sensitivity analyses of multiple model parameters. The strategy remained cost-effective unless waiting list time for an HCV-viremic kidney exceeded 3.1 years compared with the base-case value of 1.56 year.

Limitations: Estimates of waiting times for patients willing to accept an HCV-viremic kidney were based on data for patients who received HCV-viremic kidney transplants.

Conclusions: Transplanting kidneys from HCV-viremic donors into HCV-uninfected recipients increased quality-adjusted life expectancy and reduced costs compared with a strategy of transplanting kidneys from HCV-unexposed donors.

Keywords: End-stage kidney disease (ESKD); cost-effectiveness analysis; decision analysis; direct-acting agent (DAA); glecaprevir; healthcare cost; hepatitis C; kidney transplantation; medical decision making; pibrentasvir; quality-of-life (QOL); transplant waiting list.

MeSH terms

  • Adult
  • Antiviral Agents / economics
  • Antiviral Agents / therapeutic use
  • Benzimidazoles / therapeutic use*
  • Cost-Benefit Analysis
  • Donor Selection / economics
  • Donor Selection / methods
  • Drug Combinations
  • Female
  • Fluorenes / therapeutic use*
  • Hepatitis C, Chronic* / diagnosis
  • Hepatitis C, Chronic* / drug therapy
  • Hepatitis C, Chronic* / etiology
  • Hepatitis C, Chronic* / virology
  • Humans
  • Kidney Failure, Chronic / surgery*
  • Kidney Transplantation* / adverse effects
  • Kidney Transplantation* / methods
  • Male
  • Middle Aged
  • Outcome and Process Assessment, Health Care
  • Postoperative Complications* / drug therapy
  • Postoperative Complications* / economics
  • Postoperative Complications* / virology
  • Pyrrolidines / therapeutic use*
  • Quinoxalines / therapeutic use*
  • Sofosbuvir
  • Sulfonamides / therapeutic use*
  • Uridine Monophosphate / analogs & derivatives*
  • Uridine Monophosphate / therapeutic use
  • Viremia / diagnosis
  • Viremia / etiology

Substances

  • Antiviral Agents
  • Benzimidazoles
  • Drug Combinations
  • Fluorenes
  • Pyrrolidines
  • Quinoxalines
  • Sulfonamides
  • glecaprevir and pibrentasvir
  • ledipasvir, sofosbuvir drug combination
  • Uridine Monophosphate
  • Sofosbuvir