Snowsill Tristan M, Moore Jason, Mujica Mota Ruben E, Peters Jaime L, Jones-Hughes Tracey L, Huxley Nicola J, Coelho Helen F, Haasova Marcela, Cooper Chris, Lowe Jenny A, Varley-Campbell Jo L, Crathorne Louise, Allwood Matt J, Anderson Rob
Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK.
Exeter Kidney Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
Nephrol Dial Transplant. 2017 Jul 1;32(7):1251-1259. doi: 10.1093/ndt/gfx074.
Immunosuppression is required in kidney transplantation to prevent rejection and prolong graft survival. We conducted an economic evaluation to support England's National Institute for Health and Care Excellence in developing updated guidance on the use of immunosuppression, incorporating new immunosuppressive agents, and addressing changes in pricing and the evidence base.
A discrete-time state transition model was developed to simulate adult kidney transplant patients over their lifetime. A total of 16 different regimens were modelled to assess the cost-effectiveness of basiliximab and rabbit anti-thymocyte globulin (rabbit ATG) as induction agents (with no antibody induction as a comparator) and immediate-release tacrolimus, prolonged-release tacrolimus, mycophenolate mofetil, mycophenolate sodium, sirolimus, everolimus and belatacept as maintenance agents (with ciclosporin and azathioprine as comparators). Graft survival was extrapolated from acute rejection rates, graft function and post-transplant diabetes rates, all estimated at 12 months post-transplantation. National Health Service (NHS) and personal social services costs were included. Cost-effectiveness thresholds of £20 000 and £30 000 per quality-adjusted life year were used.
Basiliximab was predicted to be more effective and less costly than rabbit ATG and induction without antibodies. Immediate-release tacrolimus and mycophenolate mofetil were cost-effective as maintenance therapies. Other therapies were either more expensive and less effective or would only be cost-effective if a threshold in excess of £100 000 per quality-adjusted life year were used.
A regimen comprising induction with basiliximab, followed by maintenance therapy with immediate-release tacrolimus and mycophenolate mofetil, is likely to be effective for uncomplicated adult kidney transplant patients and a cost-effective use of NHS resources.
肾移植中需要进行免疫抑制以防止排斥反应并延长移植物存活时间。我们进行了一项经济学评估，以支持英国国家卫生与临床优化研究所制定关于免疫抑制使用的更新指南，纳入新的免疫抑制剂，并应对价格变化和证据基础的改变。
建立了一个离散时间状态转换模型，以模拟成年肾移植患者的一生。共模拟了16种不同的治疗方案，以评估巴利昔单抗和兔抗胸腺细胞球蛋白（兔ATG）作为诱导剂（以无抗体诱导作为对照）以及即释他克莫司、缓释他克莫司、霉酚酸酯、霉酚酸钠、西罗莫司、依维莫司和贝拉西普作为维持剂（以环孢素和硫唑嘌呤作为对照）的成本效益。移植物存活率是根据急性排斥反应率、移植物功能和移植后糖尿病发生率推断得出的，所有这些均在移植后12个月进行估计。纳入了国民保健制度（NHS）和个人社会服务成本。使用了每质量调整生命年20000英镑和30000英镑的成本效益阈值。
预计巴利昔单抗比兔ATG和无抗体诱导更有效且成本更低。即释他克莫司和霉酚酸酯作为维持治疗具有成本效益。其他疗法要么更昂贵且效果更差，要么只有在使用超过每质量调整生命年100000英镑的阈值时才具有成本效益。
对于无并发症的成年肾移植患者，一种包含巴利昔单抗诱导、随后即释他克莫司和霉酚酸酯维持治疗的方案可能有效，并且是对NHS资源的一种具有成本效益的使用方式。
