Frontiers in TransplantationIschemia-reperfusion injuryCost-Effectiveness of Kidney Transplantation From DCD in Italy

•The main goal of our hospital is to increase and improve transplantation medicine. Thus, in the early 2000s, we initiated a project for organ donation after cardiac death (DCD). Determination of death requires a 20-minute flat electrocardiogram, according to Italian law. After animal studies showed organ viability over the 20-minute nontouch period, the local and the national bioethics committees allowed project planning.•In 2007, the global financial crisis became real, prompting us to analyze transplantation costs in detail. We also compared brain-dead donations versus DCD versus hemodialysis. We concluded that the DCD policy is a cost-effective procedure compared with present end-stage renal disease treatment options.

IntroductionKidney transplantation represents the best therapeutic option for patients with end-stage renal disease (ESRD), providing the best outcomes for survival, quality of life, and cost-effectiveness. To increase kidney donations, in 2007, the Italian IRCCS Policlinico San Matteo Foundation in Pavia designed and conducted Programma Alba, a protocol for organ donation after cardiac death (DCD). This study evaluated the costs and health outcomes of DCD transplantation and in all types of transplants compared with current clinical practice.Patients and MethodsA Markov-based model was used to assess costs and health outcomes for new ESRD patients for 2008 to 2013. A health care founder perspective was used. Data sources were the Italian National Institute of Statistics and the Lombardy Registry of Dialysis and Transplantation. A microcosting analysis was performed to calculate costs related to clinical pathways for DCD. We assessed costs, survival, quality-adjusted survival, and cost-effectiveness.FindingsChanging the actual practice pattern for new patients with ESRD and increasing the availability of kidneys from DCD to 10 extra transplants per year will induce an incremental cost per quality-adjusted life-year of €4255. Increases in transplantation to reach an extra 10% by transplant type would result in reduced costs and increased patient survival and quality of life compared with the current scenario.InterpretationOur data show that increasing DCD transplants would result in a cost-effective policy to expand the kidney donor pool compared with current ESRD treatment patterns. Italian policies should make an effort to increase transplant rates to optimize cost-effectiveness in ESRD service supply.