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

Results

Of 206 adult renal transplantations performed at our institution between January 1997 and May 2000, 54 were LRD transplants that met inclusion criteria ( Table 1 ). 2-Haplotype matches occurred in four BAS and five control patients. The BAS group had statistically more women than men donors (p=0.0277). Two patients in each group had undergone previous transplants.

At 12 months, the frequency of acute rejection episodes was 15% (4/27) for controls and 22% (6/27) for BAS recipients. Percentages of patients experiencing acute rejection by 12 months were 11% (3/27) and 15% (4/27), respectively ( Table 2 ). Differerences in the percentage of acute rejection episodes and percentage of patients experiencing rejection were not statistically significant. Steroid-resistant rejection occurred in one BAS patient 49 days after transplantation and was unresponsive to rabbit antithymocyte globulin, plasmapheresis, and cytomegalovirus (CMV) hyperimmune globulin. The patient returned to hemodialysis.

Graft function, as measured by serum creatinine level for the first 12 months, was similar in both groups (p>0.05; Figure 1). Graft loss occurred only in BAS recipients. Of four lost grafts, only one was immunologic.

Mean serum creatinine levels at 1, 2, 3, 6, and 12 months after transplantation. Error bars represent standard error of the mean.

Cost of initial hospitalization was significantly higher in the BAS group than in controls (p=0.0003; Table 3 ). The BAS group included two outliers with initial hospitalization bills exceeding $120,000. Reasons for extended hospitalization were delayed graft function and cecectomy-ileostomy surgery secondary to cecal perforation. When costs were analyzed without these outliers, the difference still was significant ($62,935.48 vs $51,970.01, p<0.0001). Length of hospitalization decreased to a mean of 6 days for the BAS group. Further cost analysis did not reveal clear reasons for increased costs in the BAS group outside of drug costs and increases in charges for organ procurement and operating room time. Charge for BAS was approximately $6000. Results maintained significance when initial hospitalization charges were analyzed without organ procurement and operating room charges.

Readmission rates were higher in the control group but not statistically significant (67% vs 52%, p=0.33). However, mean length of stay was shorter by 0.5 days in that group (4.5 vs 5 days BAS, p>0.05). The wide difference between groups may be explained by the outlier in the BAS group who experienced steroid-resistant rejection 49 days after transplantation. When censored for this outlier, readmission charges were similar between the groups. Mean readmission charge became $10,148.50/control patient versus $12,717.14/BAS recipient, and mean length of stay became 0.5 day shorter in the BAS group (p>0.05).

Analysis of DRG payments for readmissions was also similar. The BAS group did have increased mean and median DRG amounts per readmission; however, there was no significant difference.

The frequency of infectious complications was not elevated in patients treated with BAS (Figure 2). Of readmissions, six and three were directly due to infection in controls and BAS recipients, respectively. Controls had more bacterial urinary tract and fungal infections, manifesting as oral thrush, whereas the BAS group had a slightly increased number of non-CMV infections, mainly oral herpes. No differences were statistically significant. Most invasive bacterial infections were of skin and soft tissue (cellulitis, gangrenous foot, orchitis, paronychia) or upper respiratory tract.

Number of infections/group by class. UTI = urinary tract infection; CMV = cytomegalovirus.

Cost/infectious episode was significantly higher in the BAS group ($1125.35 vs $374.84 controls, p<0.05). When factored for two significant outliers in this group with nocardial brain abscess and cellulitis, the difference maintains significance ($794.49 vs $374.84, p<0.05). Use of BAS was associated with a cost increase of $38.15/infectious episode saved without considering the outliers. Including the two major outliers in the BAS group, the cost increased to $83.39/infectious episode saved.

Cytomegalovirus infection occurred in three BAS recipients, one of whom was high risk (donor positive/recipient negative [D+/R-]) and received prophylaxis with acyclovir 800 mg orally 4 times/day for 3 months. In the control group, two cases of CMV infection occurred in D+/R+ patients who received no antiviral prophylaxis. One case of CMV occurred within 6 weeks after treatment for rejection with high-dose corticosteroids.

No infusion-related or hypersensitivity reactions were associated with BAS. The only malignancy occurred in one control patient as a basal cell carcinoma of the lip and was treated effectively with resection.

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