Cost Impact of a Novel Pre-transplant Risk Assessment Tool for Early Acute Rejection in Kidney Transplant Patients.

Background

Accurately predicting outcomes and stratifying risks remains a challenge in kidney transplant patients. The Pre-Transplant Risk Assessment (PTRA) predicts risk of early acute rejection (EAR) in deceased donor transplant recipients, enabling clinicians to tailor immunosuppression strategies using individual immune response risk.

Objectives

We developed a cost-impact analysis of adding PTRA to the current standard of care to predict the risk of EAR compared with the current protocol-driven immunosuppression in standard-risk kidney transplant patients.

Methods

A decision tree model evaluated 90-day and 2-year outcomes post kidney transplantation. PTRA testing stratified patients as either high or low risk for EAR. Reduced maintenance immunosuppression protocols were modeled in low-risk PTRA patients compared with standard protocol, reducing adverse drug event readmissions, cytomegalovirus infections, graft loss, and deaths with a functioning graft. An increased maintenance immunosuppressive regimen was modelled for high-risk PTRA patients, reducing acute rejections and graft loss.

Results

The standard-risk population cohort consisted of 71.4% low-risk PTRA and 28.6% high-risk PTRA patients. The model generated per-patient cost savings of 358 i n t h e f i r s t 90 d a y s p o s t t r a n s p l a n t a t i o n a n d 13 234 per-patient over 2 years. If PTRA were used in all 14 468 patients falling into the standard risk immunosuppression protocol, 191   475   915 c o u l d b e s a v e d o v e r 2 y e a r s a t t h e c o h o r t l e v e l . I f P T R A w e r e t o i m p a c t i n d u c t i o n i m m u n o s u p p r e s s i o n p r o t o c o l s , p e r - p a t i e n t s a v i n g s w o u l d e x c e e d 4000 over 90 days and $27 000 over 2 years. The definitions used for risk stratification and the assumed immunosuppression protocols for patient cohorts are generalized assumptions expected to align with most clinician approaches. We assumed that the reduction on clinical outcomes would be equivalent to the overall percentage of patients with expected treatment regimen impacts from PTRA. Variations in clinical decision-making regarding treatment pathways given PTRA risk stratification will influence the potential clinical impact.

Conclusions

Risk stratification with PTRA utilization prior to kidney transplant in the standard-risk population could generate significant cost savings in the 90-day and 2-year time periods post kidney transplantation.