Cost of lived related kidney transplantation and hemodialysis
During the study, Fourteen living-related kidney transplant patients at Sanglah Public Hospital Denpasar Bali Indonesia consisted of 14 recipients, 12 males, and two females aged 27–55 years and 14 donors, three males and 11 females (all-female donor are recipient's mother) aged 24–63 years were included. Thirty hemodialysis patients at the same hospital were recruited, consisting of 20 males and ten females, aged 50.9 ± 9.9 years.
Costs of hemodialysis patients were estimated by direct tangible cost for predialysis surgery (double-lumen catheter and AV fistula), hemodialysis cost twice weekly, medicines (erythropoietin and iron injection, and oral medicines), labs and radiology during out-patient visits; indirect tangible cost including transportation and meals and intangible costs due lost of income due to absence from work when hemodialysis was undertaken (estimated from regential minimum wages, stipulated by the regent regulation). Costs of kidney transplantation were estimated by direct tangible cost screening and preliminary tests and immunological tests, operation procedures (during preparation, surgery, and post-operative care), out-patients visit including medicines, labs, and tacrolimus blood assay, post-transplant hospitalization costs due to complication (infection, sepsis, severe hyperglycemia and acute kidney injury, dehydration, and malnutrition); indirect tangible cost including transportation and meals and intangible costs for loss of income due to absence from work when transplant and post-transplant procedures were undertaken (also estimated from regential minimum wages, stipulated by the regent regulation). The cost for regular visits for the recipient is considered flat after 1-year transplantation. This cost estimation is mainly applied for a recipient under five years.
Selection procedure and operation costs for recipients and donors were calculated from selection procedures, during, and post-operative care until discharge, which varied due to the patient's medical condition. Lab tests were 334,000 to 772,000 IDR according to medical conditions; blood tacrolimus assay costs were 53,340,000 IDR (for five years total), and monthly medicines costs were 3,995,000 to 19,808,000 IDR, which was calculated for regular visits according to standard procedures and hospitalization due to post-transplant complications.
Insert Table 1 here
Table 1
Costs of Living Related Kidney Transplantation during 5 years
Category | Minimum (IDR) | Maximum (IDR | Mean (IDR) | SD (IDR) |
Recipient | | | | |
Selection and operation | 138,456,100 | 337,695,400 | 182,255,442 | 46,921,425 |
Labs | 72,000,000 | 99,660,000 | 81,107,142 | 7,076,603 |
Medicines | 141,295,029 | 776,716,497 | 391,191,966 | 227,452,101 |
Transportation and meals | 6,000,000 | 18,000,000 | 7,071,428 | 3,191,678 |
Lost of income | 6,000,000. | 12,000,000 | 6,857,142 | 1,833,749 |
Donor | | | | |
Selection and operation | 36.171.900 | 87.849.600 | 58.165.000 | 13. 087.900 |
Transportation and meals | 1.500.000 | 9.000.000 | 3,107.100 | 2,294.880 |
Income lost | 3.000.000 | 9.000.000 | 6,000.000 | 2,353.390 |
Total | 437,067,200 | 1,122,686,080 | 734,950,894 | 246,825,190 |
Hemodialysis cost was 765,000 IDR per session twice weekly, Epo 997,920 IDR (twice a week in a month), intravenous iron 45,000 IRD (once a month), and oral medicine 153,800 (once a month), labs 2,718,000 IDR (once a month for 12 months), chest X-ray 145,000 IDR (once a year), and USG 270,000 IDR (once a year). Transportation cost was 15,000 to 150,000 IDR according to the distance of the patient's address to HD center and meals 20,000 to 100,000 IDR according to the distance of the patient's address to HD center. Income loss was estimated according to regential minimum wages.
Insert Table 2 here
Table 2
Costs of Hemodialysis during 5 years (N = 30)
Category | Minimum (IDR) | Maximum (IDR | Mean (IDR) | SD (IDR) |
Double lumen catheter | 2,358,900 | 8,000,000 | 4,180,526 | 1,268,290 |
AV fistula | 2,494,900 | 17,900,000 | 5,537,683 | 3,427,830 |
Hemodialysis | 397,800,000 | 397,800,000 | 397,800,000 | N/A |
Medicines | 71,803,200 | 71,803,200 | 71,803,200 | N/A |
Labs and radiology | 15,665,000 | 15,665,000 | 15,665,000 | N/A |
Transportation and meals | 13,000,000 | 130,000,000 | 41,981,333 | 28,979,392 |
Income lost | 31,200,000 | 65,000,000 | 44,546,666 | 8,013,253 |
Total | 554,085,000 | 682,327,100 | 581,514,410 | 30,302,376 |
One year mortality of kidney transplantation was 13%, 3-year mortality 20.3%, mean mortality of second and third year is 10.15%. If linear assumption after one year is made, then 5 year mortality is 13% plus 4 × 10.5% = 55%, with survival 45%.4
Sixt months of follow up, there were 18 deaths from 222 hemodialysis patients who underwent regular hemodialysis. The incidence of death outcomes was 8.11%, with a cumulative average survival time of 177.34 ± 2.00 days.5 If linear trend is assumed, five years mortality = 10 × 08.11% = 81.1% and survival rate 18.9%.
Cost-effectiveness of kidney transplant versus hemodialysis
The five-year cost of kidney transplant was 741,078 M IDR, while the five-year cost of hemodialysis was 581,514 M IDR, then the cost difference was 159,564 M IDR. Five-year mortality of kidney transplant was 55%, (survival 45%), while six-month mortality of hemodialysis was 8.11%, then five years mortality hemodialysis will be ten times 8.11% equals 81.1% (if linear trend assumed) and survival rate was 100% minus 81.1% equals 18.9%. Five years of survival difference between kidney transplant and hemodialysis was 45.0% minus 18.9% equals 26.1%, higher kidney transplant than hemodialysis.
The quality of life for a kidney transplant was 0,7063, while QOL for hemodialysis was 0,5596, then the QOL difference was 0.15. Suppose we calculate cost-effectiveness from a survival perspective, then in comparison to hemodialysis. In that case, kidney transplantation will spend 159,564 M IDR/26.1% equal 6.11 M IDR for every 1% increase of survival during five years with 0,71 − 0,56 = 0.15 point or 15% better QOL.
Data from Pakistan showed that in 5 years, 85% of kidney transplant patient was alive. With linear assumption, 50% (median survival) patients will survive 85/50 × 5 × 12 months equal to 102 months6. The median survival of hemodialysis patients was 15 months among females and 22 months in males, therefore in average median survival of HD patients was 18. 50 months.7
The difference between QOL for transplant versus hemodialysis was 71% minus 56% was 15%. QALY of the transplant was 102/12 × 0.71 equal 6.03, and QALY of hemodialysis was 18.50/12 × 0.56 equal 0.85. QALY difference transplant over hemodialysis was 6.03, minus 0.85 equals 5.14. Meanwhile, the cost difference of were159,564 M IDR. Then, the ICER was 159,564 M IDR/5.14 and yielding 31.04 M IDR per QALY