Aim: To compare the benefits and costs of incorporating an eplet-based matching algorithm to the current allocation of deceased donor kidneys to indigenous Australians.

Background: The overall waiting time for transplantation among indigenous Australians is at least six times longer than the non-indigenous Australians with end-stage kidney disease. Such disparities are largely attributed to the HLA-antigen mismatch between donors and potential indigenous transplant candidates. Structural matching within the epitope level (eplets) may provide additionally accurate assessment of immunological risk compared to HLA matching at the broad antigen level.

Methods: Using deterministic decision analytical and simulation modelling, we compared the average waiting time for transplantation, the overall survival gains (in quality-adjusted life years [QALYs] gained) and the costs of integrating an eplet-based allocation for deceased donor kidneys compared with the current allocation algorithm. The eplet-based model retrospectively simulated allocation of kidneys to indigenous recipients focusing a combination of HLA-A, -B and -DR broad antigen and eplet mismatch threshold defined by low risk of rejection.

Results: Of 34 recipients, the average waiting time for transplantation for 5 recipients (15%) was reduced by an average of 23 (SD=17) months with an algorithm using the threshold of 0-2 HLA-ABDR broad antigen mismatch with ⟨10 HLA-DR eplet mismatch for allocation (associated with low incidence of rejection). There was an average incremental gain in 0.004 QALY with average savings of $3860 using this allocation compared to the current. There was a small consequential loss of up to 0.001 QALYs and extra costs of $2005 for non-indigenous Australians.

Conclusions: Alternative allocation for indigenous kidney transplant recipients are associated with a reduction in transplant waiting-time with improved health benefits without disadvantaging non-indigenous recipients.

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