Jassal Sarbjit V, Krahn Murray D, Naglie Gary, Zaltzman Jeffrey S, Roscoe Janet M, Cole Edward H, Redelmeier Donald A
Division of Nephrology, University Health Network, Toronto, Ontario, Canada.
J Am Soc Nephrol. 2003 Jan;14(1):187-96. doi: 10.1097/01.asn.0000042166.70351.57.
Transplantation offers superior life expectancy and quality of life compared with dialysis in young patients with end-stage renal failure. However, the initial risks of mortality and morbidity are high. This study used a decision analysis model to evaluate the costs and benefits of kidney transplantation versus continued dialysis for older patients with renal failure. A decision analytic model comparing cadaveric renal transplantation to continued hemodialysis treatment was developed. The base case considered a theoretical cohort of patients aged 65 yr without known comorbidity or contraindications to transplantation who would have to wait 2 yr for a cadaveric transplant. Separate models were constructed for patients with diabetes or cardiovascular disease and for patients receiving an organ after a variety of wait-list times. Probability, utility, and survival data were obtained from published reports and renal registries. For 65-yr-old patients, quality-adjusted life expectancy increased by 1.1 quality-adjusted life years (QALY) at an incremental cost of $67,778 per QALY. Assuming a 2-yr wait-listed time, transplantation remained economically attractive for 70-yr-old patients (incremental cost effectiveness [ICE], $79,359 per QALY) but was less economically attractive for those over 75 yr of age (ICE, $99,553) or for 70-yr-olds with either cardiovascular disease or diabetes (ICE, $126,751 and $161,090 per QALY, respectively). The analytic results were sensitive only to the time spent waiting for the graft. The cost-effectiveness reduced such that the costs associated with one QALY were in excess of $100,000/yr when the probability of a complication was > or = 50% per 3-mo cycle and when the utility of transplantation fell below 0.62. If available within a timely period, transplantation may offer substantial clinical benefits to older patients at a reasonable financial cost. Prolonged waiting times dramatically decrease the clinical benefits and economic attractiveness of transplantation, suggesting that living donor transplantation may be of particular benefit in this population.
与终末期肾衰竭的年轻患者相比，肾移植能提供更高的预期寿命和生活质量。然而，早期的死亡和发病风险很高。本研究使用决策分析模型来评估肾衰竭老年患者肾移植与继续透析的成本和效益。开发了一个将尸体肾移植与继续血液透析治疗进行比较的决策分析模型。基础病例考虑了一个理论队列，该队列中的患者年龄为65岁，无已知合并症或移植禁忌证，需等待2年才能进行尸体肾移植。针对糖尿病或心血管疾病患者以及在不同等待时间后接受器官移植的患者构建了单独的模型。概率、效用和生存数据来自已发表的报告和肾脏登记处。对于65岁的患者，质量调整生命预期增加了1.1个质量调整生命年（QALY），每增加一个QALY的增量成本为67,778美元。假设等待名单时间为2年，对于70岁的患者，移植在经济上仍然具有吸引力（增量成本效益[ICE]为每QALY 79,359美元），但对于75岁以上的患者（ICE为99,553美元）或患有心血管疾病或糖尿病的70岁患者（ICE分别为每QALY 126,751美元和161,090美元），在经济上吸引力较小。分析结果仅对等待移植的时间敏感。当每3个月周期并发症的概率≥50%且移植的效用降至0.62以下时，成本效益降低，使得与一个QALY相关的成本超过每年100,000美元。如果能在及时的时间段内获得移植，那么以合理的财务成本，移植可能会给老年患者带来显著的临床益处。延长等待时间会大幅降低移植的临床益处和经济吸引力，这表明活体供体移植可能对这一人群特别有益。
