Abstract
IMPORTANCE: Many acceptable-quality deceased donor kidneys go unused every year. Older transplant candidates are more vulnerable to rapid health decline. OBJECTIVE: To assess the cost-effectiveness of increasing the kidney transplantation rate among older patients with end-stage kidney disease by using acceptable-quality deceased donor kidneys. DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation with cost-effectiveness analysis uses a microsimulation model of the kidney transplantation process for a synthetic cohort of adult candidates aged 65 years or older on the transplant waiting list between 2010 and 2019 over their remaining lifetimes. Statistical analysis was performed from January 2023 to December 2025. INTERVENTION: Increasing the transplantation rate in 5% increments higher than the status quo rate from 5% to 25% using acceptable-quality deceased donor kidneys, with a corresponding shift in the distribution of kidney quality to reflect the use of donor kidneys of lower quality than the status quo. MAIN OUTCOMES AND MEASURES: The primary outcomes were the number of key waiting list and posttransplant outcomes, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Health state transition probabilities were derived from Scientific Registry of Transplant Recipients data. Costs and quality-of-life weights were derived from published literature and US Renal Data System annual reports, all of which were varied in a probabilistic sensitivity analysis. RESULTS: In this synthetic cohort of 100 000 individuals, the mean age was 68.8 years (95% CI, 65.0-78.0 years), they had received dialysis for a mean of 1.2 years (95% CI, 0-6.6 years), 61.7% were male, and 56.8% had diabetes. It was estimated there would be 141 (range, 118-161) fewer waiting list deaths per 10 000 candidates if the deceased donor transplantation rate were increased by 25%. Increasing the deceased donor transplantation rate by 25% would cost $8100 (95% credible interval, $700-$14 100) per QALY gained or was cost saving from the health care sector and modified health care sector perspectives. From the health care sector perspective, a 25% increase in the deceased donor transplantation rate was the preferred strategy in all probabilistic sensitivity analysis samples for willingness-to-pay thresholds of $40 000 or more per QALY gained. CONCLUSIONS AND RELEVANCE: This economic analysis of increasing the kidney transplantation rate in older adults suggests that using acceptable-quality deceased donor kidneys would be cost-effective or cost saving. Decision-makers should consider policies that make better use of recovered kidneys to increase transplantation rates among older patients and any other patients with similar preferences.