Desensitization protocols and the unimportance of tissue matching are all the rage in the transplant world these days. They’re heralded as a solution to the so-called organ shortage (no matter that the ‘active’ kidney transplant list has been flat, if not declining, for many years now), and a plethora of propaganda-type media articles have followed. In fact, according to these authors, the propaganda has filtered into academic articles as well.
To be blunt:
This analysis by Axelrod et al concludes that transplanting across the ABO blood barrier “appears clinically and economically appropriate.” We think this conclusion is not justified by the analysis.
“The authors estimated Medicare spending for all covered services for 270 ABO-incompatible (ABOi) and 27 000 ABO-compatible (ABOc) transplants for the period 30 days before transplant through 3 years after transplant and found that costs for ABOi transplants were 74% higher than those for ABOc transplants.“
“The authors also estimated adjusted hazard ratios (AHRs) for both graft failure and all-cause mortality…showed that ABOi-transplanted patients had 1.9 times the risk of both death and graft failure compared with ABOc patients.”
“These estimates indicate that ABOi transplantation costs more and has a large negative impact on the health of recipients compared, with ABOc transplantation.”
Here’s an important point:
“The authors provide some evidence of a trend toward ABOi transplants being performed more frequently in patients with private insurance than in patients with Medicare insurance. This would be consistent with transplant centers being able to pass on the higher cost of ABOi transplants to private insurance companies but not to Medicare, which generally has a fixed price per transplant procedure”
Not coincidentally, the more transplants performed, the larger a surgeon’s and hospital’s revenue stream. It shouldn’t be surprising they’d promote ABO-incompatible transplants over dialysis to those with private insurance. After all, surgeons and hospitals don’t profit from dialysis. Besides, the federal government (Dept of Health and Human Services via CMS) only measure a hospital’s one-year graft and patient survival rate. What happens after that isn’t the surgeon’s or the hospital’s responsibility. So why not take the money and run?
Held, P., & McCormick, F. (2016). ABO-Incompatible Kidney Transplants: Twice as Expensive, Half as Good American Journal of Transplantation, 16 (5), 1343-1344 DOI: 10.1111/ajt.13638