Introduction: Kidney transplantation (KTx), although expensive, is a more cost effective treatment for end-stage renal disease (ESRD) than dialysis, and provides better long term survival and quality of life.

We have previously reported immunologic tolerance of renal allografts in HLA mismatched recipients following induction of transient chimerism via bone marrow transplantation (BMT). In this era of cost containment in healthcare, it is essential to assess the cost associated with such intervention.

Methods: We analyzed the economic impact of tolerance (TOL) induction (7 patients with immunosuppression free periods 5-11 years) compared to matched controls (by age, HLA match and ESRD cause) who underwent KTx with conventional immunosuppression (CONV) in the same era (37 patients).

We included hospital charges related to initial transplant procedures and all subsequent admissions, in addition to drug costs specific to transplant care (primarily immunosuppressants, antimicrobials, Insulin in patients with new onset post-transplant diabetes).

Results: Average outpatient medication cost was 2.5 times higher in CONV compared to TOL in the first year following transplant, this trend continued for the entire follow up period (up to 12 years). With stable yearly cost of medications in the CONV group, the cumulative average cost was approximately tenfold at 7 years, a trend that continued thereafter. (Figure 1)

TOL had first year hospital charges that were approximately threefold higher than CONV, primarily costs associated with conditioning and BMT. But cumulative hospital charges equalized at 11 years post-transplant, and CONV cost continued to rise at a faster rate than TOL.

Total hospital charges and outpatient drug cost shows equalization between CONV and TOL at 10 years, and a difference of $250,000/patient in favor of TOL at 12 years (Figure 2)

Conclusion: Tolerance induction through transient chimerism by donor BMT is initially more expensive, but is less costly on long term follow up, and with potential longer life of the graft it is a more cost effective approach than conventional immunosuppression.

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