*Purpose: Kidney transplantation (KT) is the optimal renal replacement therapy (RRT) for patients with end-stage renal disease (ESRD) in high-income countries (HICs) conferring the highest benefit in life expectancy, quality-of-life, and cost-effectiveness. However, in low- and middle-income countries (LMICs), which account for 48% of the global burden of ESRD, KT represents only 1% of RRT. Numerous LMICs are expanding RRT including KT. Haiti is an LMIC with an estimated 15,000 patients with untreated ESRD with RRT limited to five hemodialysis (HD) centers and no regularly active transplantation program. Plans to increase RRT capacity include a combined strategy of additional HD and the introduction of peritoneal dialysis (PD) and living-donor kidney transplantation (LDKT). The purpose of this study was to perform a cost-effectiveness analysis (CEA) of first-line RRT strategies for ESRD patients in Haiti to support the development of national RRT policy.

*Methods: We performed a CEA comparing first-line RRT strategies applicable to RRT expansion in Haiti. We created a decision analytic model comparing seven strategies: No Treatment (NT), HD-only, PD-first, LDKT-first, 5%LDKT/95%HD, 10% LDKT/90%HD, and 20%LDKT/80%HD. We considered all adult ESRD patients requiring RRT in Haiti over a lifetime horizon using the payor’s perspective. We performed a 1st order Monte Carlo Simulation using a one-year cycle length. All cost inputs and transition probabilities were derived from published literature pertaining to RRT in LMICs, historical HIC data, or Haitian in-country data. We assumed a willingness-to-pay (WTP) threshold of $2,200, based on three times GDP per capita.

*Results: The No Treatment (NT) strategy is the cost-effective RRT strategy providing 0.24 QALYs at a cost of $7,420. The LDKT-first strategy provides 5.16 QALYs at a cost of $39,704 with an incremental cost-effectiveness ratio (ICER) of $6,431 per QALY. All other strategies were strongly dominated. Acknowledging the clinical and political imperative of providing RRT, we excluded the NT strategy and performed a threshold analysis to identify the maximum initial cost of LDKT for which the LDKT-first strategy remains optimal. LDKT-first is the optimal strategy up to an initial cost of $22,898 for LDKT, or 358% of the base-case cost, after which PD became more cost-effective. A one-way sensitivity analysis suggested that LDKT is the optimal first-line strategy until age 60, above which PD became more cost-effective.

*Conclusions: All renal replacement therapy strategies in Haiti require financial expenditure. When the option to not treat is excluded, both the LDKT-first and PD-first strategies are important components of RRT policy in Haiti.

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