To determine the cost effectiveness of transplantation, we analyzed the financial economics of the organ and tissue transplant process. We compared the cost of this process with traditional modalities for treating end-stage liver and kidney disease. Medical, surgical, legal, social, ethical, and religious issues are important in organ transplant procedures. Government, health insurance companies, and uninsured individuals are affected by the financial economics of organ transplantation. The distribution of financial burden differs among countries and is dependent on the unique circumstances of each country.

Key words : Economy, Finance, Hemodialysis, Kidney transplant, Liver transplant

Introduction

The gap between supply and demand is a universal problem for organ and tissue transplantation. In some countries, transplant access is further hampered by financial obstacles. Financial costs include transplant evaluation and testing, organ procurement, transplant surgery, recipient postoperative medical care and immunosuppressive therapy, and those related to donation. In the United States (US), elderly patients > 65 years of age represent more than 25% of all transplant recipients. Kidney transplant in the elderly is associated with a marked increase in the incidence of perioperative complications and extended length of stay, which incur extra costs.1

Discussion

Health service financing systems differ among countries. In the US, insurance status and personal ability to pay significantly affect access to transplant because these procedures are expensive and the United States lacks universal health insurance for all citizens.² Decreasing financial barriers to organ transplant may increase the number of trans­plantable organs from donors.³

Rodrigue and associates⁴ conducted a multicenter prospective study, known as the Kidney Donor Outcomes Cohort Study, in which they collected cost data for 12 months following donation from 182 living kidney donors (LKDs). Most LKDs (n = 167 or 92%) incurred 1 or more direct cost following donation, including ground transportation (86%), health care (41%), meals (53%), medications (36%), lodging (23%), and air transportation (12%). Living kidney donors missed 33 072 total work hours, 40% of which were unpaid, resulting in $302 175 in lost wages (mean $1660). Caregivers lost $68 655 in wages (mean $377). Although some donors received financial assistance, 89% had a net financial loss over the 12-month period, with 33% reporting a loss exceeding $2500. Financial burden was greater for those with farther distance traveled to the transplant center, lower household income, and more unpaid work hours missed.

A study in the US reported the estimated costs of various organ transplants as of 2017. These were $414 800 for kidney and $812 500 for liver transplants. Cornea transplants were the least expensive, costing $30 200, while heart transplants were the most expensive at $1 382 400.⁵ In comparison, the cost for 1 transplant patient in Serbia over a 10-year period is €48 949 (about $40 089).⁶

It has been estimated that, based on a mean wait time for a kidney transplant of 49 months, private payers spend $250 000 to $400 000 on end-stage renal disease care over the first 33 months. When Medicare is the second insurer, Medicare spends nearly $100 000 for the additional 16 months during which it is the primary payer.⁷ In the US, the direct costs of dialysis exceed $73 000 per year per patient under the Medicare system, whereas private payments can be nearly double that amount.

A study from Japan⁸ that analyzed the cost of transplant reported that living-donor liver transplant was the most expensive transplant procedure at a total cost of ¥4.95 million or nearly $40 000. The cost of deceased-donor renal transplant was higher than the cost of living-donor renal transplant procedures: ¥3.69 million versus ¥3.55 million or $32 654 versus $31 416, respectively. The study also found that recipients of auto-peripheral blood stem cell transplant complicated by graftversus-host disease, urinary tract infection, sepsis, or pneumonia had a significantly higher average total cost during the month of transplant and the 2 following months than patients without, in addition to statistically more total treatment days.

Total additional costs of ancillary transplant activities were determined by comparing the cost of kidney transplant from living donors versus deceased donors in France. Additional transplant costs varied from €13 835 to €20 050 for a deceased donor compared with €13 601 for a living donor.⁹

Turri and associates¹⁰ evaluated the total cost of a patient on a wait list for liver transplant and the main resources related to higher costs. They found that patients on wait lists for liver transplant were subjected to many complications and incurrences that led to hospitalization and procedures that increased costs. They concluded that the patient's wait list cost for liver transplant increased as the patient's severity increased. Procedures related to treatment of hepatocellular carcinoma, the use of blood components, and hospitalization were the main cost drivers.

Rancic and associates¹¹ performed a literature review to analyze the economic feasibility of pharma­cogenetic testing in renal transplant patients. Sources from the US reported that the total cost per renal transplant was $343 300 in 2014. The authors concluded that a specific suggestion could not be made regarding use of therapeutic drug monitoring due to a lack of sufficient cost-effectiveness studies on this subject. In England, treatment of chronic renal disease comprises 1.3% of health care-related expenses.

Regardless of the source (ie, deceased, living-related, living-unrelated, or altruistic donor), the supply of kidneys does not meet the demand. It is estimated that 6.3% of kidney transplant candidates die while on a wait list.¹² Patient survival and graft survival are inversely related to length of time on dialysis.^13-15 The annual death rate for all patients on dialysis was 16.1%. The relative risk of death during the first 2 weeks after transplant was 2.8 times greater than that for patients on dialysis with similar follow-up time since wait list placement.¹⁶

In many countries, organs are being bought and sold illegally. To prevent uncontrolled trade of organs and to increase the frequency of transplant activities, it has been proposed that a regulated system of kidney sales, with a fixed price for vendors, would reduce the mortality rate of patients on wait lists. Matas and associates17 determined the most cost-effective payment amount for society and what costs would be saved by removing a patient from a wait list using a paid donor-vendor: a living-unrelated donor transplant saved $94 579, and 3.5 quality-adjusted life-years (QALY) were gained. In the illegal organ markets, kidney transplants (including certified organs) would cost about $20 000.¹⁸

Iran started a compensated and regulated living-unrelated kidney donation program in 1988 with considerable success. More than 59% of patients with end-stage kidney disease in Iran are living with a functioning graft.¹⁹ Despite being exemplary for some time, the Iranian model has serious ethical problems and it is no longer regarded as a sustainable and ethically justified system.^19,20

The idea of a regulated paid organ system has been criticized. Kahn and Delmonico²¹ reported that the ethics of organ sales should precede any analysis of the economic and practical value. They also suggested that development of a regulated system in the Western world would encourage the development elsewhere of unregulated systems without protection for vendors. The authors also expressed their concern regarding harm to the doctor-patient relationship.

In 2014, 120 000 organs were transplanted throughout the world, with 10% performed illegally. Two-thirds of these illegal transplants were kidney, followed by liver, heart, lung, and pancreas. Illicit organ trafficking is estimated to generate $840 million to $1.7 billion annually. Most vendors are young individuals from developing or underdeveloped regions, whereas the recipients are middle-aged patients with mid-to-high income from developed countries. Worldwide, 21 people die every day on average due to not being able to find a donor.²²

Organ sales are strictly forbidden by law in Turkey. Organ commerce advertisers, organ buyers, and organ sellers and brokers are punished by 9 years of imprisonment. In the case of organized crime, the penalty is 15 years of imprisonment. Turkish legislation permits living-related donors up to fourth-degree blood relatives. Unrelated-living donor candidate files are brought to the city ethics committee for a final decision.

In Turkey, the Social Security Association (Sosyal Güvenlik Kurumu; SGK) covers all employees working in state and private sectors. The system covers most of the population; individuals under the SGK umbrella have the right to free transplant procedures. No extra payment can be requested, even by private hospitals and private universities. Under defined conditions for transplant, SGK has authorized some departments to refer patients abroad for transplant to 3 centers for lung, 13 centers for heart, 30 centers for liver, 6 centers for intestine, 3 centers for pancreas, 16 centers for pediatric bone marrow, and 32 centers for adult bone marrow transplant procedures. The Baþkent University Ankara and Adana hospitals are authorized to make referrals abroad for kidney, liver, and adult bone marrow transplant. Istanbul hospital is authorized for abroad kidney referral only.²³

In Turkey, 3423 kidneys, 1396 livers, 69 hearts, 22 lungs, 6 pancreases, and 5 ileums were transplanted in 2016. Payments made by national health care for various transplants are shown in Table 1. In Turkey, it is estimated that 71 000 individuals have end-stage renal disease, and 60 000 of these patients receive hemodialysis treatment. Hemodialysis constitutes 79% of all the chronic treatment modalities for chronic renal disease. The number of patients on kidney transplant wait lists is over 23 000. Hemodialysis expenses per patient are approximately $25 000 each year, and the total cost of hemodialysis treatment is $1 billion annually.

Yiðit and Erdem²⁴ researched the cost-effectiveness of hemodialysis, peritoneal dialysis, and kidney transplant. The SGK budget for these treatment modality costs, life-years, and QALY were calculated using a Markov model. They found that the costs were ₺29.592 for hemodialysis, ₺29.061 for peritoneal dialysis, and ₺51.279 in the first year after transplant and ₺8.654 in the second and subsequent years. A transplant is cost-effective compared with both hemodialysis and peritoneal dialyses. The cost of these 3 treatment methods was ₺2.047.633.644 in 2012 in Turkey. In fact, 4.64% of the SGK's total health expenditure is estimated to be spent on hemodialysis, peritoneal dialysis, and transplant treatment.

Nations allocate an important portion of their budget to health care. Nationwide studies are needed to compare the cost-effectiveness of organ transplant compared with conservative treatment during the transplant waiting period. Major complications that lengthen hospital stay, and consequently increase the cost, should be analyzed. In countries without national health insurance, access to transplant procedures is highly limited, creating ethical issues. As financial barriers to organ transplant are reduced, an increase in transplantable organs is expected.3 Living-donor transplant shortens dialysis exposure and increases the number of kidney transplants and is cost-effective due to the lower cost per life gained by kidney transplant.

References:

1. Axelrod DA, Schnitzler MA, Xiao H, et al. The changing financial landscape of renal transplant practice: a national cohort analysis. Am J Transplant. 2017;17(2):377-389.
   CrossRef - PubMed
   
2. Laurentine KA, Bramstedt KA. Too poor for transplant: finance and insurance issues in transplant ethics. Prog Transplant. 2010;20(2):178-185.
   CrossRef - PubMed
   
3. Renkes AC. Financial barriers to organ transplantation: a comparative analysis. SPNHA Rev. 2012;8(1).
   
   
4. Rodrigue JR, Schold JD, Morrissey P, et al. Direct and indirect costs following living kidney donation: findings from the KDOC study. Am J Transplant. 2016;16(3):869-876.
   CrossRef - PubMed
   
5. Milliman Research Report. 2017 US Organ and tissue transplant cost estimates and discussion. August 2017. http://www.milliman.com/uploadedFiles/insight/2017/2017-Transplant-Report.pdf. Accessed 17 January 2018.
   
   
6. Perović S, Janković S. Renal transplantation vs hemodialysis: cost-effectiveness analysis. Vojnosanit Pregl. 2009;66(8):639-44.
   CrossRef - PubMed
   
7. Formica RN, Newell KA. What is the price of altruism? Am J Transplant. 2016;16(3):741-742.
   CrossRef - PubMed
   
8. Kitazawa T, Matsumoto K, Fujita S, Seto K, Hasegawa T. Cost analysis of transplantation in Japan, performed with the use of the national database. Transplant Proc. 2017;49(1):4-9.
   CrossRef - PubMed
   
9. Sainsaulieu Y, Sambuc C, Logerot H, Bongiovanni I, Couchoud C. [Cost of renal transplant: medico-economic analysis of the amount reimbursed by the French national health program to finance renal transplantation.] Nephro Ther. 2014;10(4):228-235.
   CrossRef - PubMed
   
10. Turri JAO, Decimoni TC, Ferreira LA, Diniz MA, Haddad LB de P, Campolina AG. Higher MELD score increases the overall cost on the waiting list for liver transplantation: a micro-costing analysis based study. Arq Gastroenterol. 2017;54(3):238-245.
    CrossRef - PubMed
    
11. Rancic N, Dragojevic-Simic V, Vavic N, Kovacevic A, Segrt Z, Djordjevic N. Economic evaluation of pharmacogenetic tests in patients subjected to renal transplantation: a review of literature. Front Public Heal. 2016;4:189.
    CrossRef - PubMed
    
12. Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol. 2001;12(3):589-597.
    PubMed
    
13. Meier-Kriesche H-U, Port FK, Ojo AO, et al. Effect of waiting time on renal transplant outcome. Kidney Int. 2000;58(3):1311-1317.
    CrossRef - PubMed
    
14. Mange KC, Joffe MM, Feldman HI. Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors. N Engl J Med. 2001;344(10):726-731.
    CrossRef - PubMed
    
15. Cosio FG, Alamir A, Yim S, et al. Patient survival after renal transplantation: I. The impact of dialysis pre-transplant. Kidney Int. 1998;53(3):767-772.
    CrossRef - PubMed
    
16. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341(23):1725-1730.
    CrossRef - PubMed
    
17. Matas AJ, Schnitzler M. Payment for living donor (vendor) kidneys: a cost-effectiveness analysis. Am J Transplant. 2004;4(2):216-221.
    CrossRef - PubMed
    
18. Kahn JP, Delmonico FL. The consequences of public policy to buy and sell organs for transplantation. Am J Transplant. 2004;4(2):178-180.
    CrossRef - PubMed
    
19. Ghods AJ. Ethical issues and living unrelated donor kidney transplantation. Iran J Kidney Dis. 2009;3(4):183-191.
    PubMed
    
20. Soofi H. Iranian kidney market in limbo: a commentary on "The ambiguous lessons of the Iranian model of paid living kidney donation." Monash Bioeth Rev. 2016;34(2):148-151.
    CrossRef - PubMed
    
21. Carney S. If you're willing to buy a kidney, you're willing to exploit the poor. http://www.scottcarney.com/2016/01/if-youre-willing-to-buy-a-kidney-youre-willing-to-exploit-the-poor/. Published 2016. Accessed 26 January 2018.
22. Clough C, May C. Transnational crime is a $1.6 trillion to $2.2 trillion annual "business," Finds New GFI Report " Global Financial Integrity. http://www.gfintegrity.org/press-release/transnational-crime-is-a-1-6-trillion-to-2-2-trillion-annual-business-finds-new-gfi-report/. Published 2017. Accessed 26 January 2018.
23. Republic of Turkey Social Security Institution (TC Sosyal Güvenlik Kurumu). http://www.sgk.gov.tr/.
24. Yiðit V, Erdem R. Cost-effectiveness analysis of dialysis and kidney transplantation in Turkey. Mehmet Akif Ersoy Üniversitesi Sos Bilim Enstitüsü Derg. 2016;1(13):182-205.