The shrinking renal replacement therapy "break-even" point

Background. This study examines the current cost of live donor (LD) transpl antation at our institution, and compares it with that of dialysis. Methods. The study population consisted of 184 consecutive adult recipients of laparoscopically procured LD kidney transplants. Cost-containment measu res instituted during this series included elimination of routine postopera tive antilymphocyte induction and an accelerated discharge clinical pathway with planned discharge of the recipient on postoperative day (POD) 2. Cost s of the transplants to Medicare were estimated from hospital charges, read mission Fates, and immunosuppressant usage, These were compared with publis hed costs of dialysis to Medicare in terms of a fiscal transplant-dialysis break-even point. Results. Kaplan-Meier patient and graft survival rates at 1 year were 97 an d 93%, respectively. Among patients followed for at least 90 days and treat ed with no induction and either cyclosporine-mycophenolate mofetil or tacro limus-mycophenolate mofetil, acute rejection rates were low (27.6 and 13.9% , respectively), In the last 124 patients, 32.3% were discharged by POD 3 a nd 71.8% by POD 6, with corresponding mean transplant hospital charges (exc luding organ acquisition) of $11,873 and $17,350, respectively. The 30-day readmission rate for patients discharged on the accelerated pathway by POD 3 was only 16%. The least expensive subgroup in the present study (30% of p atients) was that of patients discharged by POD 6 and not readmitted during the first year; the break-even point with dialysis costs was calculated as 1.7 years after the transplant. Conclusions. The cost of LD transplants can be safely reduced by eliminatio n of routine postoperative antilymphocyte immune induction and by an early discharge clinical pathway. Uncomplicated LD kidney transplants, meaning th ose with a short length of stay in the hospital after transplantation and n o need for readmission within the first year, accrue savings over dialysis within 2 years.