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Live Donor Kidney Transplantation

Altruism Alone Is Not Always Enough!

Molinari, Michele MD1; Hariharan, Sundaram MD2

doi: 10.1097/TP.0000000000002223

In this short and provocative review, the authors dissect the costs related to each step of the process of kidney living donation whatever the country, the healthcare system and the number of procedures.

1 Department of Transplant Surgery, Thomas E Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.

2 Department of Medicine, Thomas E Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.

Received 20 March 2018. Revision received 25 March 2018.

Accepted 27 March 2018.

Disclosure: The authors declare no conflicts of interest.

Correspondence: Sundaram Hariharan, MD, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Rm 755 3459 Fifth Ave, Pittsburgh, PA 15213. (

Patients with end-stage-renal disease (ESRD) undergoing renal transplantation (RT) have better long-term survival and improved quality of life as opposed to those on long-term dialysis. From an economic point of view, RT is very cost-effective1 and gives patients a chance of returning to a lifestyle similar to healthy individuals.2 Despite all these advantages, RT is limited by the organ availability and whenever possible, living donor (LD) RT should be considered as the treatment of choice for patients with ESRD.3-5 As of January 2018 in the United States alone, a total of 145 000 LD-RTs have been performed. Despite all these advantages, LD-RT exposes donors to a small but still real risk of chronic kidney disease and perioperative mortality that is currently estimated at 0.03%. Although these risks are small, they are real6 and comprehensive evaluations of all LDs are necessary to identify those with existing conditions that might lead to chronic kidney disease or shorten their life expectancy after donation.

The comprehensive medical and surgical evaluations required to guarantee that the safety of LDs can be a financial burden, not only for the donors and their families but also for the healthcare system. In the United States, the costs of evaluations and surgery are paid by the recipient's healthcare insurance,7 but the extent of financial burden encountered by the healthcare system remains unclear.8-10

In this issue of Transplantation, Habbous and colleagues11 have analyzed the incremental costs encountered by the health system for the evaluation, surgery, and follow-up care of LDs in 5 transplant centers in Ontario, Canada, during a 10-year period (2004-2014). The authors analyzed the records of 1099 LDs and reported the total incremental costs of LD-RT up to 1 year follow-up in comparison to healthy individuals. They found that, after adjusting for the expenses of healthcare costs nonrelated to donation, the incremental expenses for each LD evaluation was CAD $16 290 (95% confidence interval, CAD $15814-$16767). The cost of the evaluation did not depend on donor gender, age, or duration of the evaluation time, but was more costly in recent years. In subgroup analysis, donor evaluation costs were higher if their recipient started dialysis while the donor was being evaluated. Other important findings were that 72% of the costs were incurred in the perioperative period, and that the perioperative costs were significantly different across 5 participating transplant centers.

We applaud the investigators for the quality of their study and for dissecting out the incremental costs of LD-RT along each phase of the evaluating process because money has a strong influence on actions, evaluations, and decisions at all levels. The findings by Habbous et al11 are very important for several reasons. First and foremost, having accurate estimates allows policymakers to allocate appropriate resources to LD programs. Second, these results can help us to understand areas where costs can be minimized without jeopardizing the quality of care or safety of LDs. Third, cost estimates can be used to compare the efficiency between programs or healthcare systems.

Yet, each healthcare system is unique, and the findings of this study might not be generalizable to other countries with national healthcare systems or to countries like the United States where healthcare is delivered, for the vast majority, by private groups and the mandatory follow-up requirement after LD-RT is not 1 year, but 2 years. Nevertheless, lessons learned from Habbous’ study are valuable for all transplant centers across the world because the authors give us the opportunity to reflect on Transplant Economics.

In recent years, there has been an increasing demand for the delivery of the highest quality of care at the lowest costs without compromising the outcomes and safety of our patients. In this context of limited resources, there are several aspects of the business of transplantation that deserve our attention and might be the focus of future research in this field:

  • (i) The role of standardization across transplant programs to reduce variations and possible inefficiencies in the evaluations and delivery of care to LDs.
  • (ii) The role of a more selective allocation of resources for LDs who take longer times for the completion of their evaluations or who are at increased risk of not progressing to fruition for nonmedical reasons.
  • (iii) The use of cost-effectiveness analysis to estimate of the optimal number of evaluations that transplant centers should do to maximize the return of resources dedicated to their LD-RT programs.
  • (iv) The optimization of altruistic donations to generate the highest numbers of chain transplants at a regional level and national level. The impact on possible savings through such an approach is enormous and should be quantified.
  • (v) The possibility of redirecting resources from costly desensitization treatments of highly sensitized patients towards the use of LD-RT by using local, regional, or national exchange programs. This is already underway in the United States after the implementation of new national Kidney Allocation System (KAS) in December 2014.
  • (vi) Beyond the scope of this article, one should also consider the overall costs represented by the recipients of LD-RTs. These include the costs for their evaluations, dialysis, or other medical expenses while on the waiting list, transplant surgery, and perioperative short and long term care. In our opinion, there is a tremendous opportunity to eliminate many unnecessary expenses due to inefficiencies caused by lack of standardization in our practices.

We commend Hubbous and colleagues for their excellent analysis and for providing a clearer picture on the economic impact of LD-RT on the healthcare system. One of the main messages that emerge from their research is that, even if the savings that the healthcare system benefit from a single LD are striking, we should not overlook the fact that in the real world, each evaluation, surgery, and follow-up of LDs represent true costs for the payer.

Healthcare providers underestimate the importance of Healthcare Economics. Often, Hubbous et al remind us that we need to scrutinize the status quo to eliminate inefficiencies and barriers that erode our limited resources because “In Live Kidney Donor Transplantation, altruism alone is not always enough!”

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