Crisis Preparedness by Simulating Quality-Adjusted Life-Year Loss in Patients with End-Stage Renal Disease due to...

Background. Because of the COVID-19 pandemic, we realize that kidney transplantation (KT) suspension may become necessary. Although the impact of KT moratoriums on the mortality of candidates for KT has been reported, health-related quality of life (HRQoL) was usually not considered. For crisis preparedness, we aimed to include quality-adjusted life-years (QALYs) in the balance. Methods. We estimated 1) the health-state evolution of the French end-stage renal disease population using a semi-Markovian approach (76,980 French patients who began dialysis or were registered on the waitlist for KT between 2011 and 2019), 2) the post-KT evolution of HRQoL using a linear mixed-effects model (4,819 EQ-5D questionnaires from 2,835 French KT recipients), and 3) the HRQoL conversion for dialyzed patients according to Li's model. Results. For patients registered on the active waitlist at the beginning of the moratorium, we predicted a loss of 0.96 life-months in perfect health for a 7-mo moratorium (95% confidence interval [0.11, 1.78]). This loss was smaller for patients who become active candidates after a moratorium decision. Regardless, we reported higher losses of QALYs for patients younger than 60 y than for older patients, for every considered moratorium duration. Conclusions. KT moratoriums can be sustainable regarding both quantity and quality of life, provided they do not exceed a prolonged period. In case of future crisis with a long reduction of KT activity, we reported that priority may be proposed to the younger patients.

Our results provide arguments supporting the decision of suspending kidney transplantation activity in case of future crises, provided that the moratorium duration does not exceed a few months.We report that patients active on the waitlist at the beginning of the moratorium lose the most quality-adjusted life-years due to the suspension, particularly candidates younger than 60 y. Hence, if another crisis occurs with the possibility of maintaining only small kidney transplantation activity, giving priority to younger patients active on the list may be justified.Considering quality-adjusted life-years rather than raw survival time results in a more complete assessment of the effect of suspending kidney transplantation in patients with end-stage renal disease by taking their quality of life into account.