Purpose:

Tolerance induction is a novel therapy that enables some living donor kidney transplant recipients (LDKTR) to safely discontinue immunosuppressive (IS) therapy. We examine whether tolerance induction can generate significant lifetime savings by eliminating the need for IS therapy.

Methods:

After 14 years of experience at our center, 17 of 22 (77%) two-haplotype match LDKTR who received our tolerance induction protocol have come off IS entirely, with no allograft failures and no apparent change in patient survival. We developed a decision-analytic model of tolerance induction versus standard IS treatment to determine the expected lifetime savings if our center's experience were generalizable to all two-haplotype match LDKTR in the US. We obtained data on patient and kidney allograft survival and IS medication use in the US from a national registry, and assumed that tolerance induction with IS drug discontinuation did not affect allograft or patient survival. Tolerance induction costs approximated our institution's charges for the treatment: ∼ $48,000 USD, while IS drug costs were approximately $15,000 per year. Main outcomes were: 1) the difference in discounted (3%) lifetime costs (in 2012 USD) from tolerance induction versus standard IS treatment, and; 2) potential aggregate savings if all two-haplotype match LDKTR in the US from 2003-2012 had received tolerance induction.

Results:

In a base case simulation involving a 40 year old two haplotype match LDKTR, tolerance induction yielded an expected lifetime savings of $140,000 compared with standard IS therapy. If all 5170 two-haplotype match LDKTR between 2003 and 2012 had received tolerance induction, this could have yielded approximately $600 million in aggregate lifetime savings. Results were sensitive to the cost of tolerance induction, age of transplantation, the proportion of patients able to come off IS, and the cost of IS drug therapy.

Conclusions:

Tolerance induction in kidney transplantation may be cost saving compared with lifetime IS therapy. If our institution's experience with tolerance induction could be replicated in all US two-haplotype match LDKTR, sizeable reductions in lifetime healthcare expenses could be achieved on the population level. We did not take into account potential costs and health consequences associated with expected side effects of conventional IS therapy.

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