Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY.
Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY.
Surgery. 2021 Jan;169(1):94-101. doi: 10.1016/j.surg.2020.06.012. Epub 2020 Jul 27.
Tertiary hyperparathyroidism associated with end-stage renal disease is characterized by progression from secondary hyperparathyroidism to an autonomous overproduction of parathyroid hormone that leads to adverse health outcomes. Rates of parathyroidectomy (PTX) have decreased with the use of calcimimetics. Optimal timing of PTX in relation to kidney transplant remains controversial. We aimed to identify the most cost-effective strategy for patients with tertiary hyperparathyroidism undergoing kidney transplant.
We constructed a patient level state transition microsimulation to compare 3 management schemes: cinacalcet with kidney transplant, cinacalcet with PTX before kidney transplant, or cinacalcet with PTX after kidney transplant. Our base case was a 55-year-old on dialysis with tertiary hyperparathyroidism awaiting kidney transplant. Outcomes, including quality-adjusted life years, surgical complications, and mortality, were extracted from the literature, and costs were estimated using Medicare reimbursement data.
Our base case analysis demonstrated that cinacalcet with PTX before kidney transplant was dominant, with a lesser cost of $399,287 and greater quality-adjusted life years of 10.3 vs $497,813 for cinacalcet with PTX after kidney transplant (quality-adjusted life years 9.4) and $643,929 for cinacalcet with kidney transplant (quality-adjusted life years 7.4).
Cinacalcet alone with kidney transplant is the least cost-effective strategy. Patients with end-stage renal disease-related tertiary hyperparathyroidism should be referred for PTX, and it is most cost-effective if performed prior to kidney transplant.
与终末期肾病相关的三级甲状旁腺功能亢进症的特征是从继发性甲状旁腺功能亢进症进展为甲状旁腺激素自主过度产生，从而导致不良健康后果。甲状旁腺切除术（PTX）的比率随着钙敏感受体激动剂的使用而降低。PTX 与肾移植的最佳时机仍存在争议。我们旨在确定接受肾移植的三级甲状旁腺功能亢进症患者最具成本效益的策略。
我们构建了一个患者水平的状态转换微模拟，以比较 3 种管理方案：肾移植时使用西那卡塞、肾移植前进行西那卡塞加 PTX 或肾移植后进行西那卡塞加 PTX。我们的基本情况是一名 55 岁的透析患者，患有三级甲状旁腺功能亢进症，等待肾移植。从文献中提取包括质量调整生命年、手术并发症和死亡率在内的结果，并使用医疗保险报销数据估计成本。
我们的基本情况分析表明，肾移植前进行西那卡塞加 PTX 具有优势，成本较低，为 399287 美元，质量调整生命年较长，为 10.3 年，而肾移植后进行西那卡塞加 PTX 的成本为 497813 美元，质量调整生命年为 9.4 年，肾移植时使用西那卡塞的成本为 643929 美元，质量调整生命年为 7.4 年。
单独使用西那卡塞进行肾移植是最不具成本效益的策略。患有终末期肾病相关三级甲状旁腺功能亢进症的患者应转介进行 PTX，如果在肾移植前进行，其成本效益最高。
