Payment for Living Donor (Vendor) Kidneys: A Cost-Effectiveness Analysis

Arthur J. Matas; Mark Schnitzler

Disclosures

American Journal of Transplantation. 2004;4(2) 

In This Article

Abstract and Introduction

The supply of kidneys does not meet the demand. As a consequence, the waiting time for a cadaver kidney continues to lengthen, and there is renewed debate about payment for living donors. To facilitate this debate, we studied what amount of payment would be cost-effective for society, i.e. what costs would be saved (if any) by removing a patient from the waiting list using a paid (living unrelated: LURD) donor-vendor. A Markov model was developed to calculate the expected average cost and outcome benefits of increasing the organ supply and reducing waiting times by adding paid LURD organs to the available pool.

We found that a LURD transplant saved $94,579 (US dollars, 2002), and 3.5 quality-adjusted life years (QALYs) were gained. Adding the value of QALYs, a LURD transplant saved $269,319, assuming society values additional QALYs from transplantation at the rate paid per QALY while on dialysis.

At a minimum, a vendor program would save society >$90,000 per transplant and provides QALYs for the ESRD population. Thus, society could break even while paying $90,000/kidney vendor.

The major clinical problem in kidney transplantation today is the shortage of donor organs. The significant improvement in transplant patient and graft survival in the last two decades[1] and the clear demonstration that long-term survival is better after a transplant (vs. dialysis) for patients with end-stage renal disease (ESRD)[2,3] have led an increasing number of patients with ESRD to opt for transplantation. In addition, acceptance of older patients as transplant candidates has markedly increased the potential number of recipients.

A kidney transplant can come from either a living or cadaver donor. In the United States during the last decade, despite numerous local and national educational attempts and media promotions, there has been little increase in the number of cadaver donors. With recognition of the excellent outcome with living unrelated donors (LURDs) and in response to the organ shortage, there has been some increase in the number of living donors.[4]

The net result is that each year more patients join the waiting list than are transplanted. As a consequence, the waiting list and the resultant waiting time to transplantation have continued to increase.[4] The Scientific Registry of Transplant Recipients (SRTR) database shows that between 1988 and June 2002, the number of patients on the waiting list for a kidney transplant increased from 13,943 to 52,766.[4] Currently, in most areas of the country, the average waiting time for a cadaver kidney is approaching or has exceeded 5 years. These long waits not only are expensive (dialysis costs approximately $50,000 per year) but also have a negative impact on post-transplant outcome; both patient survival and graft survival are inversely related to length of time on dialysis.[5,6,7] In addition, the number of patients dying while on the kidney transplant waiting list has increased from 736 in 1988 to 2,875 in 2000.[4]

Clearly, altruistic donation is not providing sufficient organs. One potential solution is to consider payment to donors or to donor families. Numerous authors have debated the ethics for and against paid donation[8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34]; and a proposal has recently been made to consider a small payment to families of cadaver donors as an 'ethical incentive'.[34] Herein, we do not debate the ethics, but we asked what payment our society could potentially 'afford' to provide for a living donor. Our answer helps establish the framework for the ethical debate.

We studied what amount of payment to a living donor (vendor) would be cost-effective for society, i.e. what costs would be saved by removing a patient from the waiting list using a paid LURD (vendor). We show, herein, that payment for living donor kidneys could be cost-effective for the US health care system. For our analysis, we have assumed the establishment of a government-regulated system where a fixed price is paid to the donor, and where the kidneys are allocated by a predefined algorithm similar to the extant UNOS point system. Of note, in the United States, the government or private insurance pays the costs of long-term dialysis.

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