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Published on: April 12, 2021
Optimal patient selection for simultaneous heart-kidney transplant: A modified cost-effectiveness analysis
Brian Wayda1, Xingxing S Cheng2, Jeremy D Goldhaber-Fiebert3
1Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California.
Insights
Simultaneous heart-kidney transplants use scarce donor kidneys. A safety net strategy, where a kidney is only transplanted if native kidneys fail post-heart transplant, is more efficient for most patients.
Area of Science:
- Transplantation Medicine
- Organ Allocation Policy
- Nephrology
Background:
- Rising rates of simultaneous heart-kidney (SHK) transplants strain deceased donor kidney (DDK) availability.
- Current organ allocation policies lack specific eligibility criteria for SHK transplants.
- Comorbid kidney dysfunction is common in heart transplant candidates.
Purpose of the Study:
- To evaluate the efficiency of SHK transplants versus a "Safety Net" strategy for heart transplant candidates with kidney dysfunction.
- To identify patient subsets who benefit most from SHK transplants.
- To inform the development of objective criteria for SHK transplant eligibility.
Main Methods:
- Decision-analytic modeling was employed to compare SHK and Safety Net strategies.
- Quality-adjusted life year (QALY) gains were calculated for DDK allocation scenarios.
- Efficiency was assessed based on QALYs gained per DDK used.
Main Results:
- For an average candidate with 50% native kidney recovery probability post-heart transplant, SHK yielded 0.64 more QALYs but used 0.58 more DDKs than Safety Net.
- SHK was less efficient (1.1 QALYs/DDK) than kidney transplant-only (2.2 QALYs/DDK) in this average scenario.
- SHK was only preferred over Safety Net for candidates with a low native kidney recovery probability (24%-38%).
Conclusions:
- A Safety Net strategy is generally more efficient for allocating DDKs compared to SHK transplants.
- SHK transplants are only justifiable for specific patient groups with a high likelihood of kidney failure post-heart transplant.
- Objective criteria, favoring a Safety Net approach, should be established for SHK transplant eligibility.
Abstract:
Increasing rates of simultaneous heart-kidney (SHK) transplant in the United States exacerbate the overall shortage of deceased donor kidneys (DDK). Current allocation policy does not impose constraints on SHK eligibility, and how best to do so remains unknown. We apply a decision-analytic model to evaluate options for heart transplant (HT) candidates with comorbid kidney dysfunction. We compare SHK with a "Safety Net" strategy, in which DDK transplant is performed 6 months after HT, only if native kidneys do not recover. We identify patient subsets for whom SHK using a DDK is efficient, considering the quality-adjusted life year (QALY) gains from DDKs instead allocated for kidney transplant-only. For an average-aged candidate with a 50% probability of kidney recovery after HT-only, SHK produces 0.64 more QALYs than Safety Net at a cost of 0.58 more kidneys used. SHK is inefficient in this scenario, producing fewer QALYs per DDK used (1.1) than a DDK allocated for KT-only (2.2). SHK is preferred to Safety Net only for candidates with a lower probability of native kidney recovery (24%-38%, varying by recipient age). This finding favors the implementation of a Safety Net provision and should inform the establishment of objective criteria for SHK transplant eligibility.
Related Concept Videos
01:28Kidney Transplant I: Introduction
01:26Kidney Transplant II: Surgical Procedure
01:16Kidney Transplant III: Nursing Management