Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania; and.
Renal-Electrolyte Division, Department of Medicine and.
Clin J Am Soc Nephrol. 2018 Feb 7;13(2):290-298. doi: 10.2215/CJN.05080517. Epub 2017 Oct 12.
Management strategies are unclear for late-onset cytomegalovirus infection occurring beyond 6 months of antiviral prophylaxis in cytomegalovirus high-risk (cytomegalovirus IgG positive to cytomegalovirus IgG negative) kidney transplant recipients. Hybrid strategies (prophylaxis followed by screening) have been investigated but with inconclusive results. There are clinical and potential cost benefits of preventing cytomegalovirus-related hospitalizations and associated increased risks of patient and graft failure. We used decision analysis to evaluate the utility of postprophylaxis screening for late-onset cytomegalovirus infection.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used the Markov decision analysis model incorporating costs and utilities for various cytomegalovirus clinical states (asymptomatic cytomegalovirus, mild cytomegalovirus infection, and cytomegalovirus infection necessitating hospitalization) to estimate cost-effectiveness of postprophylaxis cytomegalovirus screening strategies. Five strategies were compared: no screening and screening at 1-, 2-, 3-, or 4-week intervals. Progression to severe cytomegalovirus infection was modeled on cytomegalovirus replication kinetics. Incremental cost-effectiveness ratios were calculated as a ratio of cost difference between two strategies to difference in quality-adjusted life-years starting with the low-cost strategy. One-way and probabilistic sensitivity analyses were performed to test model's robustness.
There was an incremental gain in quality-adjusted life-years with increasing screening frequency. Incremental cost-effectiveness ratios were $783 per quality-adjusted life-year (every 4 weeks over no screening), $1861 per quality-adjusted life-year (every 3 weeks over every 4 weeks), $10,947 per quality-adjusted life-year (every 2 weeks over every 3 weeks), and $197,086 per quality-adjusted life-year (weekly over every 2 weeks). Findings were sensitive to screening cost, cost of hospitalization, postprophylaxis cytomegalovirus incidence, and graft loss after cytomegalovirus infection. No screening was favored when willingness to pay threshold was <$14,000 per quality-adjusted life-year, whereas screening weekly was favored when willingness to pay threshold was >$185,000 per quality-adjusted life-year. Screening every 2 weeks was the dominant strategy between willingness to pay range of $14,000-$185,000 per quality-adjusted life-year.
In cytomegalovirus high-risk kidney transplant recipients, compared with no screening, screening for postprophylactic cytomegalovirus viremia is associated with gains in quality-adjusted life-years and seems to be cost effective. A strategy of screening every 2 weeks was the most cost-effective strategy across a wide range of willingness to pay thresholds.
对于巨细胞病毒高风险（巨细胞病毒 IgG 阳性对巨细胞病毒 IgG 阴性）肾移植受者在抗病毒预防 6 个月后发生的迟发性巨细胞病毒感染，管理策略尚不清楚。已经研究了混合策略（预防后筛查），但结果不一致。预防巨细胞病毒相关住院和相关患者和移植物失败风险增加的临床和潜在成本效益。我们使用决策分析来评估预防迟发性巨细胞病毒感染后筛查的效用。
设计、设置、参与者和测量：我们使用马尔可夫决策分析模型，结合各种巨细胞病毒临床状态（无症状巨细胞病毒、轻度巨细胞病毒感染和需要住院治疗的巨细胞病毒感染）的成本和效用，来估计预防后巨细胞病毒筛查策略的成本效益。比较了 5 种策略：不筛查和筛查间隔为 1、2、3 或 4 周。严重巨细胞病毒感染的进展是基于巨细胞病毒复制动力学建模的。增量成本效益比是通过比较低成本策略之间的成本差异与质量调整生命年的差异来计算的。进行了单向和概率敏感性分析以测试模型的稳健性。
随着筛查频率的增加，质量调整生命年有了增量收益。增量成本效益比为每质量调整生命年 783 美元（每 4 周筛查一次，不筛查）、每质量调整生命年 1861 美元（每 3 周筛查一次，每 4 周筛查一次）、每质量调整生命年 10947 美元（每 2 周筛查一次，每 3 周筛查一次）和每质量调整生命年 197086 美元（每周筛查一次，每 2 周筛查一次）。发现筛查成本、住院成本、预防后巨细胞病毒发病率和巨细胞病毒感染后的移植物丢失对筛查结果敏感。当支付意愿阈值<14000 美元/质量调整生命年时，不筛查更有利，而当支付意愿阈值>185000 美元/质量调整生命年时，每周筛查更有利。在支付意愿范围为 14000 美元至 185000 美元/质量调整生命年之间，每 2 周筛查一次是最具成本效益的策略。
在巨细胞病毒高风险的肾移植受者中，与不筛查相比，筛查预防后巨细胞病毒病毒血症与质量调整生命年的增加相关，并且似乎具有成本效益。在广泛的支付意愿范围内，每 2 周筛查一次是最具成本效益的策略。
