OBJECTIVES

To compare cost and effectiveness between two choices: 1) renal transplantation (RT) from a HCV+ donor (D+) into HCV- recipient (R-) followed by immediate direct acting antiviral (DAA) therapy; 2) R- continuing dialysis and waiting for RT from a HCV- donor (D-).

METHODS

A decision tree model was developed for the comparison over a 5-year time frame, using a payer’s perspective. Effectiveness was measured in expected years of life (YOL) using data extracted from United States Renal Data System (USRDS) 2016 Annual Report. Costs (adjusted in 2017 USD) included direct expenditures for RT and immediate care post-RT, immunosuppressive therapy, dialysis and associated medication costs while awaiting RT, and 12 weeks of DAA for D+/R- patients. Indirect and intangible costs were not modeled. National Average Drug Acquisition Costs were used to estimate DAA costs. Costs for other services were extracted from either the USRDS 2016 Annual Report or the Centers for Medicare & Medicaid Services payment database. D-/R- patients were examined at the end of year 2, year 3, and year 4 during the 5-year frame, assuming that the probability of getting a RT increased each year (25% in year 2, 50% in year 3, and 75% in year 4).

RESULTS

The D+/R- strategy resulted in an expected 4.6 YOL with an expected total cost of $153k compared to 3.6 YOL and $264k for the D-/R- strategy. The D+/R- strategy remained dominant after one-way sensitivity analyses on RT survival probability, DAA therapy cure rate, waiting time on dialysis in D+/R- strategy, cost of kidney transplant and DAA treatment, year during which dialysis patients received a RT, and dialysis survival probability while awaiting RT in D-/R- strategy.

CONCLUSIONS

The innovative D+/R- strategy followed by treating the HCV with DAA is less costly and more effective compared to the traditional D-/R- strategy.