Share this article on:

Cost-Effectiveness of Cidofovir Treatment of Polyomavirus Nephropathy in Kidney Transplant Recipients

Hua, Danny K.1; Howard, Kirsten2; Craig, Jonathan C.1,2; Chapman, Jeremy R.3; Wong, Germaine1,2,3,4

doi: 10.1097/TP.0b013e31823e7b0e
Clinical and Translational Research

Background. BK virus nephropathy (BKVAN) causes about 10% of late kidney graft loss. Cidofovir is widely used to treat BKVAN, but the magnitude of the health benefits and costs are largely unknown. We aimed to evaluate the incremental health benefits and costs of cidofovir and immunosuppression reduction compared with immunosuppression reduction alone in kidney transplant patients with BKVAN.

Methods. A probabilistic decision analytic model was developed to simulate a cohort of kidney transplant recipients aged 45 years and above with BKVAN who received cidofovir treatment compared with those who received standard care. The duration of the cycle was 1 year, and the model terminated when all recipients were deceased.

Results. Compared with immunosuppression reduction alone, in the base-case, the incremental health benefits of cidofovir were 0.0061 life-years saved (2.2 days), with savings of $20,756 over the lifetime of a transplant recipient. When varying the most influential variables (the probability of response to treatment and graft loss) between best and worst case scenarios, the incremental health outcomes ranged from −0.967 to 1.093 life-years saved, with incremental costs ranging from an extra $27,313 to saving $20,756.

Conclusions. Compared with immunosuppression reduction alone, based on best available data, cidofovir treatment and immunosuppression reduction for BKVAN seem to be cost saving and improves health outcomes. However, because of weak clinical data, particularly around comparative effectiveness, there is still moderate uncertainty in the incremental cost effectiveness. Adequately powered trials are still needed to better define optimal treatment strategies for BKVAN before cidofovir can be recommended strongly as routine therapy.


1Centre for Kidney Research, Children's Hospital at Westmead, Australia.

2School of Public Health, University of Sydney, Sydney, New South Wales, Australia.

3Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia.

The authors declare no funding or conflicts of interest.

Address correspondence to: Germaine Wong, M.B.B.S., M.Med. (ClinEpi), Ph.D., F.R.A.C.P., The Children's Hospital at Westmead, Locked Bag 4001, Sydney, New South Wales 2006, Australia. E-mail:

D.K.H. designed and performed the research, analyzed data, and wrote the manuscript; K.H. participated in research design, advised on performance of the research and data analysis, and contributed to writing of the manuscript; J.C.C. and J.R.C. participated in data analysis and writing of the manuscript; and G.W. participated in research design, performance of the research, data analysis, and writing of the manuscript.

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (

Received 30 August 2011. Revision requested 26 September 2011.

Accepted 21 October 2011.

The development of more effective immunosuppressive agents for kidney transplant recipients has significantly reduced the risk of early acute graft rejection, but at the expense of opportunistic infections and cancer (1). In particular, polyomavirus-associated nephropathy is increasingly recognized as an important cause of allograft failure, attributing up to 10% of late graft loss (1, 2).

BK virus, a DNA polyomavirus, exists in a latent state in the tubular epithelial cells of the kidney in 60% to 80% of the general population (3). The virus is reactivated with immunosuppression. Approximately 35% to 57% of renal transplant recipients develop BK viruria, of which 33% to 51% progress to viremia (4, 5). The prevalence of BK virus nephropathy (BKVAN) in renal transplant recipients is 1% to 10%, resulting in subsequent graft loss in 10% to 80% (2).

Evidence to support the current management strategies for BKVAN is limited. International guidelines suggest judicious immunosuppression reduction, but this is associated with greater risk of rejection (2), and no particular regime has proven superior (6). Other than immunosuppression reduction alone, cidofovir and leflunomide are the two most frequently studied and commonly used agents in patients with established BKVAN (7). However, the evidence to support the routine use of cidofovir and leflunomide are restricted to observational studies, with substantial heterogeneity in sample sizes, follow-up time, and treatment regimens (7).

In the absence of trial-based evidence, the next best alternative to inform clinical decision making is decision analytical modeling. Using time-dependent probabilities, such modeling can systematically calculate the long-term health benefits and costs of the interventions of interest (8), and it is useful to inform clinicians and decision makers about the efficiency of the intended intervention for decision making. The aims of this study are 2-fold. First, to estimate the healthcare costs and outcomes of cidofovir and immunosuppression reduction treatment for BKVAN in renal transplant recipients compared with immunosuppression reduction alone. Second, to identify factors that may impact on the cost-effectiveness of cidofovir treatment in recipients with BKVAN.

Back to Top | Article Outline


Characteristics of Included Studies

The clinical outcomes published in the observational studies and the time-adjusted values used in the model are shown Appendix 1, SDC 1 ( A total of 19 studies with sample size ranging from 1 to 88 in the immunosuppression reduction alone arm and 7 studies with sample size from 4 to 26 in the adjuvant cidofovir arm were included in the analyses. Paired data were available from six studies, which were used in both arms. The average follow-up time was 1.86 in the immunosuppression reduction alone arm and 1.92 years in the adjuvant cidofovir arm. The proportion of patients who responded to treatment without any form of rejection ranged from 20% to 100% and 64% to 100% annually in the immunosuppression reduction alone arm and adjuvant cidofovir arm, respectively. Of those who responded to treatment, 6.0% (0%–33%) in the immunosuppression alone arm and 3.1% (0%–17%) in the adjuvant cidofovir arm experienced some form of biopsy-proven rejection within the 12-month time-adjusted period. It was assumed that graft loss was due to BKVAN if the diagnosis was not specified.

Back to Top | Article Outline

Base-Case Analysis

The total cost for treatment with immunosuppression reduction alone was $280,669, compared with $259,914 for treatment with immunosuppression reduction and cidofovir, a difference of $20,756 favoring cidofovir. The average benefits associated with immunosuppression reduction alone and immunosuppression plus cidofovir treatment were 8.237 and 8.243 patient life-years saved (LYS), respectively. Compared with immunosuppression reduction alone, the incremental health benefits associated with immunosuppression reduction and cidofovir treatment were 0.0061 patient life-years (or 2.2 days of life saved). Intervention with immunosuppression reduction plus cidofovir “dominates” the alternative, being both less expensive and more effective.

Back to Top | Article Outline

Extreme Case Scenarios

The best and worst case scenarios were determined using the most and the least favorable estimates of the influential variables in the model. Under the best-case scenario (probability of graft loss=2.5%, probability of response to cidofovir without rejection=86.99%, and probability of response to immunosuppression reduction alone=56.25%), the incremental health benefits when using cidofovir were 1.093 LYS while costing $82,822 less. Under the least favorable conditions (probability of graft loss=7%, probability of response to cidofovir without rejection=63.75%, and probability of response to immunosuppression reduction alone=79.99%), the incremental health benefits were −0.967 LYS and the incremental costs were $27,313.

Back to Top | Article Outline

Sensitivity Analyses

The tornado diagram (Fig. 1) shows the variability in the incremental net health benefits tested over a range of plausible values for the influential variables using one-way sensitivity analyses. The model was most sensitive to the probability of response without rejection when treated with both immunosuppression reduction and cidofovir. Figure 2 shows the extent of this variability plotted on a cost-effectiveness plane comparing the two treatment regimens. The x-axis represents the incremental gains in life-years, and the y-axis represents the incremental costs comparing immunosuppression reduction with immunosuppression reduction and cidofovir treatment. The incremental health outcomes varied between 0.84 fewer life-years and an additional 0.09 life-years; the incremental costs varied from an additional $23,379 to saving $24,883 when the probability of response to treatment was varied between 0.6375 and 0.8699, respectively. The findings from the probabilistic sensitivity analysis showed similar results, with all simulations extending across −4.18 to 3.53 LYS on the cost-effectiveness plane regardless of the predefined willingness-to-pay threshold.





Back to Top | Article Outline


Our study suggests that cidofovir treatment for BKVAN in kidney transplant recipients saves lives and money. Compared with immunosuppression reduction alone, cidofovir and immunosuppression reduction saves a total of 2.2 days of life and reduces costs by $20,756. Although it may appear attractive to accept adjuvant cidofovir and immunosuppression reduction as a standard treatment for BKVAN, clinicians and policy makers should be aware of the major uncertainties underpinning this approach. Uncertainties exist in the probability of response to treatment with immunosuppression reduction and cidofovir and the probability of acute rejection with immunosuppression reduction. If the probability of response is reduced by a plausible 0.19%, treatment with cidofovir and immunosuppression reduction will not incur any extra health benefits compared with immunosuppression reduction alone. The negative outcomes of adjunctive cidofovir from potential nephrotoxicity and neutropenia may off-set any benefits in treating BKVAN.

To our knowledge, this is the first modeled analysis that evaluates the overall and incremental health outcomes and costs of using cidofovir for the treatment of BKVAN. Our study has several strengths. An extensive literature search was conducted using broad search terms to identify relevant studies. In the absence of randomized controlled trials, pooling data from observational studies was the most appropriate method for obtaining clinical data (9). Other clinically relevant data such as estimates of patient and graft survival were sourced from the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry, a comprehensive database that prospectively collects detailed information such as incidence, prevalence, and survival data on all patients on renal replacement therapy in Australia and New Zealand since 1963 (10). A probabilistic model was used to better capture the uncertainty in multiple variables simultaneously, by employing parameter distributions rather than point estimates. This provides a better estimate of the joint uncertainty in decision making, instead of assessing the variability of the point estimates in a single dimension.

Our study has a number of limitations. First, outcomes were not estimated using quality-adjusted life-years due to a paucity of data. Cost-utility analyses are useful when the quality of life differs between intervention and control groups or between different health states. It is likely that utility-based quality of life adjustment values would differ greatly between those with graft loss and those cured from BKVAN. Utility-based quality of life data are available for transplant recipients without comorbidities, but there are no published estimates for recipients with co-existing illnesses such as BKVAN. Utility-based quality of life assessment will provide quality of life weights that are essential to quantify health benefits in quality adjusted life-years, reflecting the realistic impacts of the disease and the effects of cidofovir treatment on patients. Second, our clinical estimates of cidofovir were sourced from retrospective observational studies, with limited comparative, long-term efficacy data to model the change of treatment benefits over time. In addition, other novel adjuvant treatments such as mammalian target of rapamycin inhibitors and quinolones were not included in our modeled analyses. Finally, we have not considered indirect costs such as productivity losses due to the time spent in ambulatory care for parenteral cidofovir treatment.

Similar to the findings from published literature, results from our base-case analyses have shown comparable graft survival outcomes in recipients with BKVAN treated with cidofovir and with immunosuppression reduction alone. Our model estimated an annual risk of graft loss of 14.8% using immunosuppression reduction and cidofovir treatment compared with an annual risk of graft failure of more than 20% if immunosuppression reduction alone was used. A review by Hirsch et al. (2) described the graft failure rates of reduced immunosuppression, which ranged from 10% to 80% over a variable follow-up period. A recent systematic review reported a pooled graft failure rate of 8 per 100 patient-years for immunosuppression reduction alone and immunosuppression reduction plus cidofovir (11). A review of case series showed an average risk of graft loss of 23% among those who received cidofovir and immunosuppression reduction compared with 17% among those who were treated with leflunomide and immunosuppression reduction (7). A single cost- analysis had quantified the total average costs of immunosuppression reduction therapy for BKVAN but did not consider the comparative effectiveness and costs of the newer cidofovir treatment (12). The reported average costs of the reduced immunosuppression regime for BKVAN were $6,000 to $11,000, which are comparable with our estimated total average costs (12).

In the face of much uncertainty regarding the treatment of BKVAN, and the relatively common occurrence of disease, a guide for clinical decision making is needed urgently. Decision analytic modeling allowed us to systemically collate the available evidence in the setting of uncertainty, while making the assumptions, evidence, and uncertainties explicit, which is not achievable through any other methods. Although the included evidence are based predominately on observational data with small sample sizes, this approach is more satisfactory than relying on nonevidence-based implicit clinician judgment as is currently the case.

Back to Top | Article Outline

Future Research and Policy Implication

Given in vitro antiviral properties of cidofovir, mediated through the later stages of T-cell expression (13), it is likely that cidofovir may be of benefit for the treatment of BKVAN in kidney transplant recipients. However, its therapeutic use in patients with impaired renal function is limited by its nephrotoxic properties as it accumulates within the tubular cells causing acute kidney injury (14). The total treatment dose, the frequency of treatment, and the mode of delivery of this potentially valuable agent are largely unclear. Given the burden of polyomavirus and the variability in the reported outcomes of the current treatment regimens (2, 7), a well-designed and adequately powered randomized controlled trial, with patient focused clinical outcomes is urgently needed to resolve some of the major uncertainties for the treatment of BKVAN in kidney transplant recipients. A randomized controlled trial assessing clinical effects associated with using cidofovir for treating BKVAN such as graft function, risk of rejection, drug tolerability, and safety is near completion and may provide valuable information for the treatment of this debilitating illness in kidney transplant recipients (15).

Back to Top | Article Outline


Despite the favorable results of our base-case analyses, substantial variability exists in the sensitivity analyses indicating that the cost-effectiveness of cidofovir treatment remains uncertain within the limits of our assumptions. We have identified the key influencing parameter as the relative risk of responding without rejection. Results vary greatly with small changes in this parameter, from providing increased benefit at a lower cost, to harm at a lower cost, to harm at an increased cost. In the absence of other proven beneficial agents for the treatment of BKVAN, it may be safe and clinically worthwhile to treat using the current recommended dose of cidofovir in combination with judicious immunosuppression reduction. However, this study highlights the need for better quality data in the form of randomized controlled trials to assess the efficacy, cost-effectiveness, and cost-utility of using cidofovir and other potential antiviral agents such as leflunomide, its derivatives, the fluoroquinolones, and intravenous immunoglobulin in conjunction with immunosuppression reduction, versus immunosuppression reduction alone, for the treatment of BKVAN.

Back to Top | Article Outline


Using a central healthcare funder perspective, a probabilistic Markov model was developed to simulate the progression of renal transplant patients from diagnosis with BKVAN to death. The model was structured to include the natural consequences of BKVAN in kidney transplant recipients. We then populated the model using relevant clinical and cost data from published literature and the ANZDATA registry (Tables 1 and 2). Finally, uncertainties in parameters were tested using deterministic and probabilistic sensitivity analyses. The model began at age 45, reflecting the median age of transplantation in Australia (16), had an annual cycle length and ceased when all transplant recipients were dead.





Back to Top | Article Outline

Structure of Model

The simplified structure of the model is shown in Figure 3. It uses a hypothetical cohort of kidney transplant recipients with biopsy-proven BKVAN. The model has two arms: immunosuppression reduction alone and immunosuppression reduction in conjunction with weekly cidofovir treatment.



In both arms, immunosuppression was reduced according to the recommendations by the Kidney Disease: Improving Global Outcomes guidelines (6): calcineurin inhibitors were reduced by 50%, followed by conversion from mycophenolate to either leflunomide or azathioprine. In the cidofovir treatment arm, we assumed regular adjunctive cidofovir treatment for a total of six doses. The number of cidofovir treatments were based on those used to achieve clinical remission in three observational studies (17 19).

Transplant recipients could respond to therapy without acute rejection, respond to treatment but experience rejection, have no response to treatment in addition to rejection, or have no response to treatment but no rejection. Individuals who experienced any of the four different scenarios could survive with no graft loss, survive with graft loss, or die. Individuals could experience recurrence of BKVAN or have no recurrence of disease.

The transition of individuals through mutually exclusive health states were based on both fixed and age-specific probabilities (Table 1) and incurred costs related to the specific health states (Table 2). Total costs and health outcomes were accrued over the patient's lifetime.

Back to Top | Article Outline

Model Outcomes

The model outcomes were total costs and health outcomes, measured in LYS, of treating BKVAN with immunosuppression reduction or immunosuppression reduction plus cidofovir. An incremental cost-effectiveness ratio is calculated using these values according to the following formula.

Future costs and benefits were discounted by 5% per year. Half-cycle corrections were used. TreeAge Pro Suite 2009 (TreeAge Software, Williamstown, MA) was used to develop and run the model.

Back to Top | Article Outline

Input Parameters for the Model

Clinical Data

A literature search was conducted using the Medline and Embase databases to define transition probabilities for the model (for search terms, see Appendix 2, SDC 1, Observational studies involving the treatment of BKVAN with either immunosuppression reduction (18 36) or immunosuppression reduction in conjunction with cidofovir (18, 19, 24, 26, 30, 32, 37) were selected. Case reports, case series, animal studies, pediatric studies, and studies with insufficient data were excluded (Table 1).

Patient outcome data (rejection and response) were extracted from the studies and converted to annual probabilities by the following method. A follow-up time of 1 year was used for any studies with unknown follow-up time or had a follow-up time of less than 1 year.

Patients without response or with rejection:

Patients with response without rejection:

All rates were then pooled for use in the model using the formula:

Data regarding graft loss, dialysis outcome, or death were derived from the ANZDATA registry between 1985 and 2008 (16).

Back to Top | Article Outline

Cost Data

All costs were adjusted to 2009 Australian dollars (using Australian Institute of Health and Welfare health price deflators) (38). Only direct healthcare costs were included. Costs of procedures were obtained from the Australian Medicare Benefits Schedule (39) and costs of drugs from the Australian Pharmaceutical Benefits Scheme (40) and the published literature (41 43) (Table 2).

Back to Top | Article Outline

Sensitivity Analysis

One-way sensitivity analyses were used to assess the influence of individual parameters on the model results. A tornado diagram was constructed by varying all the parameters individually, by 25% in both directions and between the published 95% confidence intervals, and plotting the range of their net health benefits against the extremes of the plausible estimates. The incremental net health benefits aims to combine the incremental cost and effect values by incorporating a predefined willingness-to-pay threshold of $50,000 per life-year gained. This is calculated according to the following formula (8).

Probabilistic sensitivity analysis was also undertaken. Instead of using point estimates for parameter values, this approach assigns distributions to model parameters, and samples from those distributions using Monte Carlo simulations (8). We used beta distributions for the treatment outcome probabilities (the probability of response or rejection after treatment). Dirichlet distributions were used for nonbinary probabilities.

Back to Top | Article Outline


1. Tantravahi J, Womer KL, Kaplan B. Why hasn't eliminating acute rejection improved graft survival? Annu Rev Med 2007; 58: 369.
2. Hirsch HH, Brennan DC, Drachenberg CB, et al.. Polyomavirus-associated nephropathy in renal transplantation: Interdisciplinary analyses and recommendations. Transplantation 2005; 79: 1277.
3. BK virus. Am J Transplant 2004; 4(suppl 10): 89.
4. Brennan DC, Agha I, Bohl DL, et al.. Incidence of BK with tacrolimus versus cyclosporine and impact of preemptive immunosuppression reduction [Erratum appears in Am J Transplant 2005; 5(4 pt 1): 839]. Am J Transplant 2005; 5: 582.
5. Bressollette-Bodin C, Coste-Burel M, Hourmant M, et al.. A prospective longitudinal study of BK virus infection in 104 renal transplant recipients. Am J Transplant 2005; 5: 1926.
6. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant 2009; 9(suppl 3): S1.
7. Hilton R, Tong CYW. Antiviral therapy for polyomavirus-associated nephropathy after renal transplantation. J Antimicrob Chemother 2008; 62: 855.
8. Drummond MF, Sculpher MJ, Torrance GW, et al.. Methods for the economic evaluation of health care programmes [ed. 3]. New York, Oxford University Press 2005.
9. Selvin S. Survival analysis for epidemiologic and medical research: A practical guide. Cambridge, New York, Cambridge University Press 2008.
10. Webster AC, Supramaniam R, O'Connell DL, et al.. Validity of registry data: Agreement between cancer records in an end-stage kidney disease registry (voluntary reporting) and a cancer register (statutory reporting). Nephrology 2010; 15: 491.
11. Johnston O, Jaswal D, Gill JS, et al.. Treatment of polyomavirus infection in kidney transplant recipients: A systematic review. Transplantation 2010; 89: 1057.
12. Kiberd BA. Screening to prevent polyoma virus nephropathy: A medical decision analysis. Am J Transplant 2005; 5: 2410.
13. Bernhoff E, Gutteberg TJ, Sandvik K, et al.. Cidofovir inhibits polyomavirus BK replication in human renal tubular cells downstream of viral early gene expression. Am J Transplant 2008; 8: 1413.
14. Ortiz A, Justo P, Sanz A, et al.. Tubular cell apoptosis and cidofovir-induced acute renal failure. Antivir Ther 2005; 10: 185.
15. National Institute of Allergy and Infectious Disease. Identifier NCT00138424, A randomized, placebocontrolled, dose-escalation study to assess the safety and effect of cidofovir in renal transplant recipients with BK virus nephropathy; 2011. Available at: NCT00138424. Accessed March 10, 2011.
16. Australia and New Zealand Dialysis and Transplant Registry. The 32nd Annual Report. Adelaide, ANZDATA Registry 2009.
17. Kuypers DRJ, Vandooren A-K, Lerut E, et al.. Adjuvant low-dose cidofovir therapy for BK polyomavirus interstitial nephritis in renal transplant recipients. Am J Transplant 2005; 5: 1997.
18. Kuypers DRJ, Bammens B, Claes K, et al.. A single-centre study of adjuvant cidofovir therapy for BK virus interstitial nephritis (BKVIN) in renal allograft recipients. J Antimicrob Chemother 2009; 63: 417.
19. Wu S-W, Chang H-R, Lian J-D. The effect of low-dose cidofovir on the long-term outcome of polyomavirus-associated nephropathy in renal transplant recipients. Nephrol Dial Transplant 2009; 24: 1034.
20. Howell DN, Smith SR, Butterly DW, et al.. Diagnosis and management of BK polyomavirus interstitial nephritis in renal transplant recipients. Transplantation 1999; 68: 1279.
21. Randhawa PS, Finkelstein S, Scantlebury V, et al.. Human polyoma virus-associated interstitial nephritis in the allograft kidney. Transplantation 1999; 67: 103.
22. Barri YM, Ahmad I, Ketel BL, et al.. Polyoma viral infection in renal transplantation: The role of immunosuppressive therapy. Clin Transplant 2001; 15: 240.
23. Li R-M, Mannon RB, Kleiner D, et al.. BK virus and SV40 co-infection in polyomavirus nephropathy. Transplantation 2002; 74: 1497.
24. Ramos E, Drachenberg CB, Portocarrero M, et al.. BK virus nephropathy diagnosis and treatment: Experience at the University of Maryland Renal Transplant Program. Clin Transpl 2002: 143.
25. Celik B, Shapiro R, Vats A, et al.. Polyomavirus allograft nephropathy: Sequential assessment of histologic viral load, tubulitis, and graft function following changes in immunosuppression. Am J Transplant 2003; 3: 1378.
26. Tong CYW, Hilton R, MacMahon EME, et al.. Monitoring the progress of BK virus associated nephropathy in renal transplant recipients. Nephrol Dial Transplant 2004; 19: 2598.
27. Wali RK, Drachenberg C, Hirsch HH, et al.. BK virus-associated nephropathy in renal allograft recipients: Rescue therapy by sirolimus-based immunosuppression. Transplantation 2004; 78: 1069.
28. Kim HC, Hwang EA, Han SY, et al.. Polyomavirus nephropathy after renal transplantation: A single centre experience. Nephrology 2005; 10: 198.
29. Nampoory MRN, Johny KV, Pacsa A, et al.. BK virus nephropathy in renal transplant recipients in Kuwait: A preliminary report. Transplant Proc 2005; 37: 3048.
30. Gupta G, Shapiro R, Thai N, et al.. Low incidence of BK virus nephropathy after simultaneous kidney pancreas transplantation. Transplantation 2006; 82: 382.
31. Giraldi C, Noto A, Tenuta R, et al.. Prospective study of BKV nephropathy in 117 renal transplant recipients. New Microbiol 2007; 30: 127.
32. Ison MG, Parker M, Stosor V, et al.. Development of BK nephropathy in recipients of simultaneous pancreas-kidney transplantation. Transplantation 2009; 87: 525.
33. Takayama T, Ito T, Suzuki K, et al.. BK virus nephropathy: Clinical experience in a university hospital in Japan. Int J Urol 2009; 16: 924.
34. Teschner S, Gerke P, Geyer M, et al.. Leflunomide therapy for polyomavirus-induced allograft nephropathy: Efficient BK virus elimination without increased risk of rejection. Transplant Proc 2009; 41: 2533.
35. Akpinar E, Ciancio G, Sageshima J, et al.. BK virus nephropathy after simultaneous pancreas-kidney transplantation. Clin Transplant 2010; 24: 801.
36. Huang G, Chen L-Z, Qiu J, et al.. Prospective study of polyomavirus BK replication and nephropathy in renal transplant recipients in China: A single-center analysis of incidence, reduction in immunosuppression and clinical course. Clin Transplant 2010; 24: 599.
37. Scantlebury V, Shapiro R, Randhawa PS, et al.. Cidofovir: A method of treatment for BK virus-associated transplant nephropathy. Graft 2002; 5: 82.
38. Australian Institute of Health and Welfare. Health Expenditure Australia 2008–09. Health and welfare expenditure series no. 42. Cat. no. HWE 51. Canberra, ACT: AIHW 2010.
39. Australian Government Department of Health and Aging. Medicare benefits schedule book. Canberra, ACT: AIHW 2011.
40. Australian Government Department of Health and Aging. Pharmaceutical benefits scheme. Canberra, ACT: AIHW 2011.
41. Cass A, Chadban S, Craig JC, et al.. The economic impact of end-stage kidney disease in Australia. Melbourne, Kidney Health Australia 2006.
42. New South Wales Department of Health. Resource distribution formula technical paper. Sydney, NSW: NSW Health 2005.
43. Kardamanidis K, Lim K, Da Cunha C, et al.. Hospital costs of older people in New South Wales in the last year of life. Med J Aust 2007; 187: 383.

Cost-effectiveness; Cidofovir; Polyomavirus; BK virus; BKVAN; Transplant

© 2012 Lippincott Williams & Wilkins, Inc.