Restricting cadaveric kidney transplantation based on age: the impact on efficiency and equity

Caring for patients with end-stage renal disease (ESRD) is resource intense, and health care costs for this small segment of the population continue to rise. When compared to long-term dialysis as a therapy for ESRD, kidney transplantation increases survival, improves quality of life, and is cost saving.

We used decision analytic techniques to determine if cadaveric kidney transplantation is cost-effective in all age groups. We then looked at the impact of a strategy of restricting access to transplantation to those under 60 years of age to determine the impact on overall clinical outcomes and costs, as well as the outcomes and costs within each age group.

Equal access to cadaveric kidney transplantation resulted in an increase in expected life years (7.4 vs 6.7 years) and a significant cost savings ($376,577 vs $568,670 per patient) compared to a strategy of long-term dialysis therapy over a 25-year time horizon. This pattern was seen for the overall cohort, and for all four age groups individually. Restricting access to transplantation to patients under the age of 60 resulted in only a very small improvement in expected life years and small cost savings under base-case assumptions. As expected, older patients were adversely impacted by this strategy.

We have shown that transplantation is cost-effective for all age groups. A strategy of restricting access to transplantation to younger patients does not result in large cost savings and provides only small improvements in expected life-years at the expense of significantly worse outcomes in older patients.