Lack of Economic Benefit With Basiliximab Induction in Living Related Donor Adult Renal Transplant Recipients

Jason A. Crompton, Pharm.D., Troy Somerville, Pharm.D., Lonnie Smith, Pharm.D., Jacke Corbett, FNP-C, Edward Nelson, M.D., John Holman, M.D., Fuad S. Shihab, M.D.

Disclosures

Pharmacotherapy. 2003;23(4) 

In This Article

Abstract and Introduction

Study Objective: To assess the effect of basiliximab (BAS) induction therapy on acute rejection rates and overall costs in adult living related donor (LRD) renal transplant recipients.
Design: Retrospective chart review and cost-effectiveness analysis of the first 12 months after transplantation.
Setting: University hospital and outpatient renal transplant clinic.
Patients: Sixty consecutive adult LRD renal transplant recipients.
Intervention: The treatment group received BAS 20 mg intravenously on postoperative days 0 and 4. The control group received no induction agents. Both groups received cyclosporine microemulsion, azathioprine, and corticosteroids for maintenance immunosuppression.
Measurements and Main Results: Six patients (three in each group) were excluded; three had received muromonab-CD3 as an induction agent and three were lost to follow-up. At 12-months, the frequency of acute rejection episodes was 15% (4/27) in the control group and 22% (6/27) in the BAS group (NS). Renal function, as measured by average serum creatinine level, was similar at months 1, 2, 3, 6, and 12 for both groups. The frequency of infectious complications was similar in both groups. No adverse effects were associated with BAS. Mean initial hospitalization charges were $51,970.01 and $68,093.90 in the control and BAS groups, respectively (p<0.05). The control group had more readmissions (18 vs 14 in the BAS group), but the average charge/readmission was lower ($10,148.50 vs $21,952.58 in the BAS group; NS). All costs were adjusted to 2000 dollars (US).
Conclusion: Basiliximab induction therapy did not provide clear clinical efficacy benefit or prove to be cost-effective compared with no induction in LRD recipients.

Renal transplantation provides significant quality-of-life and economic benefits for patients with end-stage renal disease, and decreases long-term mortality over that in patients receiving dialysis awaiting transplantation.[1,2,3,4,5] In addition to reducing strain on donor sources, the use of living related donors (LRD) may decrease the amount of time spent undergoing dialysis while awaiting transplantation and increase patient survival.[6]

The key to long-term graft survival is effective immunosuppression while limiting toxicity and comorbidity from the agents. Recent advances allowed the development of several immunosuppressants with specific immune system targets that have the potential to extend graft half-life. With the shift to a more economically focused health care system, optimum therapeutic protocols are necessary to provide the greatest cost-effectiveness.

Induction therapy after transplantation is controversial, especially in LRD renal transplant recipients, whose survival rates are generally superior to those for cadaveric donor transplant recipients.[7,8,9] Induction therapy reduces acute rejection rates and provides adequate immunosuppression until oral maintenance immunosuppressive agents reach therapeutic levels. Two potential risks of augmented immunosuppression with induction agents are increased rates of infection and malignancy.[10,11,12] These risks, together with the cost of the agents, may not outweigh any decrease in acute rejection.

The interleukin-2 receptor (IL-2R) antagonists basiliximab (BAS) and daclizumab have an unusual mechanism of action. These monoclonal antibodies bind to the IL-2R of activated T lymphocytes to prevent further lymphocyte stimulation and proliferation triggered by IL-2. Their utility in renal transplantation was reported in randomized, double-blind, placebo-controlled trials.[13,14,15] All trials used cadaveric kidneys with or without human leukocyte antigen (HLA)-mismatched LRDs. Pharmacoeconomic data showed cost savings based on outcomes of these trials.[16,17,18]

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