The Economic Burden of Kidney Graft Failure in the United States

Jesse Sussell; Alison R. Silverstein; Prodyumna Goutam; Devin Incerti; Rebecca Kee; Corinna X. Chen; Donald S. Batty Jr; Jeroen P. Jansen; Bertram L. Kasiske


American Journal of Transplantation. 2020;20(5):1323-1333. 

In This Article

Abstract and Introduction


Despite improvements in outcomes for kidney transplant recipients in the past decade, graft failure continues to impose substantial burden on patients. However, the population-wide economic burden of graft failure has not been quantified. This study aims to fill that gap by comparing outcomes from a simulation model of kidney transplant patients in which patients are at risk for graft failure with an alternative simulation in which the risk of graft failure is assumed to be zero. Transitions through the model were estimated using Scientific Registry of Transplant Recipients data from 1987 to 2017. We estimated lifetime costs, overall survival, and quality-adjusted life-years (QALYs) for both scenarios and calculated the difference between them to obtain the burden of graft failure. We find that for the average patient, graft failure will impose additional medical costs of $78 079 (95% confidence interval [CI] $41 074, $112 409) and a loss of 1.66 QALYs (95% CI 1.15, 2.18). Given 17 644 kidney transplants in 2017, the total incremental lifetime medical costs associated with graft failure is $1.38B (95% CI $725M, $1.98B) and the total QALY loss is 29 289 (95% CI 20 291, 38 464). Efforts to reduce the incidence of graft failure or to mitigate its impact are urgently needed.


Over the past 5 years, the number of kidney transplants performed in the United States has increased steadily. In 2017, 17 644 kidney transplants were performed in the United States, compared to 16 487 transplants in 2012.[1] It is well-established that kidney transplantation offers patients the opportunity for longer lives and higher quality of life than long-term dialysis treatment, so long as transplanted grafts continue to function.[2,3]

Outcomes for kidney transplant recipients have improved substantially in the past decade. Between 2005 and 2015, 6-month all-cause and death-censored graft failure in deceased-donor recipients decreased from 7.5% and 4.3%, respectively, to 4.8% and 2.6%; in living donor recipients, 6-month all-cause graft failure was only 1.3% in 2015.[4] Between 1998 and 2006, 10-year all-cause graft failure rates fell from 57.2% to 51.6%, and death-censored graft failure rates fell from 33.7% to 26.2%.[4] Studies have also consistently found meaningful gains in quality of life for transplant recipients.[5–9]

Despite these improvements, graft failure continues to impose substantial costs on society.[4] The direct medical costs associated with graft rejection and graft failure are known to be large. For example, when graft failure results in a return to dialysis (as is routine), costs of medical care increase by an estimated $79 479 (2018 USD) per year.[10] Repeat transplantations may be performed, but these increase medical costs by an estimated $154 643 (2018 USD).[11]

Although much is known about the impact of graft failure at the individual level, its population-wide economic burden has yet to be quantified. Economic burden of disease studies seek to measure the aggregate burden imposed on society by a disease or condition, encompassing both the direct medical costs incurred, as well as the monetized value of impact on health-related quality of life. This study aims to estimate this quantity for different populations of kidney transplant recipients in the United States by comparing two different scenarios of a simulation model of the health and economic outcomes of kidney transplant patients in the United States: one in which patients are at risk for graft failure and one in which they are not.