Health Technology Assessment of Kidney Transplantation and Hemodialysis for the Treatment of End-Stage Kidney Disease

Kidney transplantation is an expensive procedure, and it is an alternative treatment of end-stage renal disease other than dialysis. Cost-Effectiveness and the cost-utility study was undertaken at Sanglah Hospital Bali Indonesia, aiming to assess whether living-related kidney transplantation is more cost-effective and cost-utility than hemodialysis in the treatment of end-stage renal disease. A health technology assessment was done in living-related kidney transplant and hemodialysis during 2018. Data search from internet resources using the electronic library and critically appraised the best evidence of the data of the best data of ve-year mortality and survival of kidney transplant and hemodialysis. A preliminary study about quality of life was also done among kidney transplant and hemodialysis patients. Data about kidney transplant costs and hemodialysis for ve years was taken from the Sanglah General Hospital database. independent best

evidence of the data of the best data of ve-year mortality and survival of kidney transplant and hemodialysis. A preliminary study about quality of life was also done among kidney transplant and hemodialysis patients. Data about kidney transplant costs and hemodialysis for ve years was taken from the Sanglah General Hospital database.

RESULTS
During the study, Fourteen living-related kidney transplant patients at Sanglah Public Hospital Denpasar Bali Indonesia consisted of 14 recipients, 12 males, and 2 females aged 27 -55 years, and 14 donors, three males and 11 females aged 24-63 years were included. Thirty HEMODIALYSIS patients at the same hospital were recruited. They consisted of 20 males and ten females, with an average age of 50.9 years. The average ve-year cost of kidney transplant was 741,078 M IDR. In  The HTA aims to evaluate whether living-related kidney transplantation is more cost-effective and costutility than hemodialysis in treating end-stage renal disease.

Methods
A retrospective analysis was done in living-related kidney transplant and hemodialysis at Sanglah General Hospital, Bali Indonesia, during 2018. The study was started with a focus group discussion involving evidence-based medicine appraisals to search data resources on the internet using the electronic library and critically appraised the best evidence of the data. This appraisal is undertaken by two independent appraisals to obtain the best data of ve-year mortality and survival of kidney transplant and hemodialysis patients in cohort study both in Indonesia and abroad. Whenever there are no full ve years of survival data, a linear trend is assumed to obtain ve years of survival using the maximum

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 (doublelumen catheter and AV stula), 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 postoperative 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 at after 1-year transplantation. This cost estimation is mainly applied for a recipient under ve 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 ve 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 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 Several studies regarding the cost comparison of kidney transplantation and hemodialysis exist. For the rst year in Palestine, the total per-patient cost for kidney transplantation was 13 317 USD and 2960 USD ( a total16 277 USD). In comparison, the mean cost for hemodialysis for each patient was 16 085 USD per year. Both costs are similar. While after transplant, the cost continues at 2960 USD per year for each patient. Therefore, the rst-year cost (16 277 USD) of kidney transplantation was fully offset in just 1.24 years by the yearly cost savings of 13 125 USD (16 085 USD for dialysis minus 2960 USD for kidney transplantation. [8] Some similar studies on cost-effectiveness between kidney transplantation and hemodialysis have been conducted. A study by Sanchez-Escuredo et al. was done in 2014 with the use of prospective descriptive study. They compared the cost between LDKT (living-donor kidney transplantation) during one year after transplantation and hemodialysis. The total cost of LDKT was 29,879.91 Euro, in which 8.128,44 Euro for the cost for donor and 21,769.47 Euro for a recipient. Hemodialysis's total cost was 43,000.88 Euro, which 37.917 Euro for hemodialysis treatment and related procedures and 5,028 Euro for transportation, respectively. Thus, it could be concluded that LDKT had produced cost-saving 13.102,97 Euro per patient per year capital payback period for less than one year. On the other hand, the quality-adjusted life-year (QALY) of LDKT was higher in LDKT than hemodialysis. It was known that LDKT is associated with a higher quality of life within one year after transplantation and more cost-effective. [9] Another study by Dominguez J and Atal R in 2011 conducted cost-effectiveness analysis and quality of life. They implemented the Markov model between kidney transplantation and dialysis. It was found that the cost estimation of dialysis was 134.000 USD with 4.32 quality-adjusted life-year (QALY). Simultaneously, the cost for transplantation was 106,000 USD, with 7.3 QALY, which produced 28,000 USD net saving and 2.98 QALY gain. Assuming, if 25,000 USD is considered yielding perfect health condition within one year; therefore, the subsequent transplantation can produce an estimated total saving of 102,000 USD. [10] As for Pakistan's situation, the "free" transplantation costs to SIUT (Sindh Institute of Urology and Transplantation) are $1640 for transplant surgery and $300 per month for immunosuppressive drugs. A total of $1.6 million was spent by SIUT each year only on transplantation with overall, the one-and veyear graft. Patient survival is 88% and 65% and 90% and 75%, respectively. [6] Although the cost of the rst year after transplantation is expensive for Korea, over two years it becomes more effective and less costly than hemodialysis. It has been recommended that kidney transplantation is more cost-effective than hemodialysis. Kidney transplantation was less exorbitant and had a better result than hemodialysis. The cost per QALY gained was 19,450 thousand won in transplantation patients. In contrast, it was 36,514 thousand won per QALY gained in hemodialysis patients. [11] In Indonesia, in 2013, a presidential decree on national health insurance has been issued. This national health insurance is run by BPJS, a national insurance body. Since 2014 the BPJS has reported that renal failure patients are the second top among catastrophic diseases after heart disease, which claimed 161.606.000 USD. [1] Compared to Greece, hemodialysis cost more than €171 million, or €182 per session, and €229 per inpatient day. It is also calculated that 2,046 years are lost due to mortality, and €9.9 million for the potential productivity cost, according to the human capital approach, and €303.000, based on the friction method. It was estimated as more than €273 million for total morbidity cost due to absence from work and early retirement, based on the human capital approach; the friction method was estimated as €12.5. In Greece, the population of ESRD patients depletes around 2 percent of total health expenditure. The mortality and morbidity of the disease also contribute to production loss. [12] Problems of high economic and health burden due to end-stage renal disease make the government seek another approach. Our kidney transplantation is more costly; however, it is more cost-effective than hemodialysis. The QALY for transplant and QALY for hemodialysis was 6.03 and 0.85, respectively. The cost-utility for lived kidney transplantation was 31.04 M IDR per QALY or 2,217 USD per QALY (exchange rate 14,000 IDR per USD). A study by Dominguez et al., found that QALY for dialysis and QALY for kidney transplantation was 4.32 and 7.3, respectively, leading to 2.98 QALY gain and 25,000 USD per QALY (a condition of perfect health condition within one year). Less e cient procedures in our hospital due to an expensive blood test, laboratory examination such as HLA matching and blood tacrolimus measurement conducted in another region, and CT angio conducted in another center, may be responsible for the higher cost kidney transplantation. These problems may occur since our program still in the early phase