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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 22  |  Issue : 2  |  Page : 71-85

Kidney transplantation versus dialysis in Zimbabwe: a systematic review of the cost-effectiveness


1 Zimbabwe Kidney Foundation, Harare, Zimbabwe
2 Institute of Life Course and Medical Sciences, Faculty of Medicine, University of Liverpool, UK
3 Sheffield Teaching Hospital, Sheffield Kidney Institute, University of Sheffield, Sheffield, UK

Date of Submission15-Oct-2021
Date of Acceptance03-Nov-2021
Date of Web Publication19-May-2022

Correspondence Address:
Dr. Moyo Obadiah
Zimbabwe Kidney Foundation, 20 Lanark Road, Belgravia, Avondale, Harare
Zimbabwe
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jesnt.jesnt_31_21

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  Abstract 


In Zimbabwe, the population of patients with chronic kidney disease is rising, putting a strain on the nation’s few dialysis treatment centers, whether government or private. The government covers the whole expense of delivering dialysis in the government facilities, increasing the financial burden. Patients from both public and private dialysis units opting for kidney transplantation (KT) are referred abroad at high foreign currency costs. The goal of this study focused on reviewing the economic advantage of KT in relation to renal dialysis as a means of establishing a KT program in Zimbabwe. Economic advantage studies on KT versus renal dialysis were obtained using various digital resources. The search strategy was based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations. Economic assessment tools such as the Markov model, cost–utility analysis, cost-effective analysis were utilized to substantiate the relevance of KT in improving survival of end-stage renal disease patients at a lower expenditure. In studies where cost-effectiveness between KT and dialysis was compared, it was shown that KT is a cheaper solution with a higher quality of life than dialysis. It was also shown in most of the studies that among the dialysis modalities, hemodialysis (HD) was more expensive than peritoneal dialysis (PD). In one of the studies, the cost values were Euro 36 000 for HD, Euro 26 000 for PD, and Euro 11 000 for KT. The quality-adjusted life years per patient were 0.46 for HD, 0.49 for PD, and 0.61 for KT. As far as cost-effectiveness and raising the health status, wellness level, good living, and survival, KT is rated highly and a better modality than dialysis. It is a more appropriate renal treatment for introduction in Zimbabwe to save on the scarce foreign currency. The barriers to the commencement of KT were identified, and the solutions were enumerated.

Keywords: cost–benefit analysis, cost-effectiveness, economic evaluation, hemodialysis, kidney transplantation, Markov model, peritoneal dialysis, quality-adjusted life years


How to cite this article:
Obadiah M, Carl S, Ahmed H. Kidney transplantation versus dialysis in Zimbabwe: a systematic review of the cost-effectiveness. J Egypt Soc Nephrol Transplant 2022;22:71-85

How to cite this URL:
Obadiah M, Carl S, Ahmed H. Kidney transplantation versus dialysis in Zimbabwe: a systematic review of the cost-effectiveness. J Egypt Soc Nephrol Transplant [serial online] 2022 [cited 2022 Jul 5];22:71-85. Available from: http://www.jesnt.eg.net/text.asp?2022/22/2/71/345437




  Introduction Top


Background

The worldwide chronic kidney disease statistics

The public health burden of chronic kidney disease (CKD) [1], which is a noncommunicable disease, rose worldwide with a prevalence of 29.3% between 1993 and 2017. Globally in 2017, there was 697.5 million CKD cases and 1.2 million deaths from CKD [1]. In Zimbabwe, the published prevalence and deaths for CKD in 2017 were 944 836 and 1740, respectively [1]. The major worldwide causes of CKD are diabetes and hypertension [2], while aspects like HIV [3]), toxins [4], and aging [5] are also contributory to the disease burden.

End-stage renal disease (ESRD) is the terminal and invariable stage of CKD [5]. When kidneys are unable to sustain life, then renal replacement therapy (RRT) becomes necessary. The advent of RRTs made it possible for long-term, lifesaving, but treatment is expensive for patients with ESRD. In 2010, there were more than 2.6 million persons on RRT globally, and this estimate is forecast to grow to 5.4 million by 2030 [6]. The three forms of RRT are kidney transplantation (KT), hemodialysis (HD), and peritoneal dialysis (PD) [7]. In 2016, one-third of the world countries performed below 20% KT, and in one-quarter of the nations, 50–70% KT was done, giving a total of 89 823 [8],[9]. In 2016 at 80% prevalence, HD at in-centers was the most applied RRT in 79% of the countries. Many countries have also created policies that favor of the initial use of PD as it is cheaper than HD and yields an improved quality of life (QOL) [10],[11],[12],[13].

The KT prevalence in 2017 was 90 306 and 95 479 in 2018 [9]. A higher CKD prevalence and mortality were recorded during the period between 1990 and 2017. This resulted in a reduction in the global age standard rate of CKD-related disability-adjusted life years (DALYs) by 8.6%. In 2017, CKD resulted in 7.3 million years lost to disability, 28.5 million years of life lost, and 35.8 million DALYs [1].

Position statement

Chronic kidney failure cases are rising in Zimbabwe due to hypertension, diabetes, and population aging (about 1000 cases per million annually). This results in a high requirement for dialysis therapy in public and commercial dialysis facilities across the nation. The government covers the whole expenditure of HD in government sector dialysis facilities for all individuals on renal replacement treatment, resulting in tremendous financial demand. The majority of patients in both public and commercial dialysis centers seek KT overseas. The expense of transplantation overseas is covered by the government’s limited hard currency appropriations, which are supplied to public and private patients through health insurance firms. These hard currency expenses have risen dramatically, prompting the government to explore the possibility of having KT s done locally.

Purpose of the study

The government has expressed political openness to facilitate the development of a living donor-related KT program. Nevertheless, understanding the economics of doing KT against the present expenses of administering dialysis is critical. The cost-effective data of KT-related procedures has not been thoroughly studied in Zimbabwe. A thorough analysis of all KT-related cost–utility analysis (CUA) findings will assist the government in identifying the most cost-effective approaches that have the most value for investment. All examples presented are personnel skills development and wages, consultations, medical and surgical costs, imaging, and diagnostic tests such as tissue typing, immunosuppressive, and essential medications. The expenses of infrastructure building and restoration are equally significant.

This research aimed to determine the economic advantage of KT in contrast to dialysis to create a KT program in Zimbabwe.

Hypothesis

The assumption is that if Zimbabwe establishes a KT center, it will have a beneficial effect, as several researchers have demonstrated KT to be a less expensive but more successful treatment option than alternative RRTs [5]. It is very well known that the advent of appropriate immunosuppressive treatments for KT has improved survival and QOL [14].

Conceptual framework

To make an accurate judgment, it was necessary to examine the expenditure disparities between modes of renal treatment in at least one nation close to Zimbabwe and other low-income, middle-income, and higher-income countries. Review of publications whereby cost-effective analysis (CEA) was conducted utilizing techniques such as the Markov model to explain the relevance of KT in enhancing health, wellness, good living, and improved survival at a lower cost was considered [15].

CUA is the most often used economic assessment tool to guide financial decisions [16]. CUA has the added benefit of including patient-identified results and evaluating a wide range of possible outcomes used in the assessment compared with other economic evaluation methods. CUA’s primary endpoint is the ratio of change in net costs to change in total medical benefits [17].

Incremental cost-effectiveness ratio (ICER) is used to examine the effectiveness of alternative therapies [5], and choices are taken under the constraints of the overall ‘willingness to pay rate’ for medical benefits [17].

The quality-adjusted life year (QALY) and the DALY are two standard health indicators utilized to help assess clinical outcomes dependent on a person’s lifespan and well-being.

The QALY became the first established state of health measure, and it has been widely used. A QALY is described as 1 year of good health. As a result, a QALY represents the number of stable years obtained. A DALY is a unit of measurement for the number of stable years missed. As a result, health measures aim to improve QALYs while avoiding DALYs [18]. A QALY value of ‘0’ represents death, while a value of ‘1’ represents absolute well-being. This is in contrast with a DALY, where ‘0’ denotes good health, and ‘1’ denotes death. In terms of efficacy results, QALY is used as the primary outcome factor [19].

Most of the research in this extensive literature review used Markov models to quantify the benefits and costs of potential improvements in RRT use. Their frequent use is usually to describe stochastic variables that change over time and predict chronic disease development. Groups of prospective patients switch through preconfigured medical levels throughout a period, based on transition probabilities throughout a specified timeframe. Every health state’s costs and clinical outcomes measure the predicted cost and benefits throughout a period. The chances of going out of one health state do not rely on the states a patient has encountered before entering that state, which is a significant drawback called ‘memorylessness.’ While being a technical constraint, it is feasible to resolve the ‘memoryless’ presumption by rearranging. For instance, by combining a wide variety of health states to model specific patient information and using time-dependent projections, we can account for the fact that a patient’s chances of a transplant vary according to what period they were on dialysis treatment [20],[21].

EuroQOL (EQ-5D), Time Trade-Off (TTO), SF-6D/SF-36 health survey, Health Utilities Index, and Standard Gamble (SG) are some of the tools used to calculate utility values in most of the articles reviewed [5],[22],[23],[24],[25].


  Aims Top


The primary aims of this study were to examine research studies that looked at the economic advantage of renal replacement treatments and KT in developing and developed countries. Second, to look at research studies that used methods like the Markov model and CUA to explain KT’s relevance in improving health, wellness, good living, and increasing survival at a lower cost. Third, to apply the conclusion to Zimbabwe and make recommendations.

The secondary aims were to identify the barriers to transplantation in Zimbabwe and to suggest solutions to promote transplantation as a national program in Zimbabwe.


  Methodology Top


Search strategy

The search technique was based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations [5],[26]. Economic advantage studies of KT versus renal dialysis were obtained using a variety of digital resources, such as the National Health Service Economic Evaluation Database [5],[27], PubMed [28], Google Scholar [29], as well as public service websites and health strategy statements.

The main words, cost–benefit analysis, cost-effectiveness, KT, economic evaluation, HD, PD, and QALY, were searched using Medical Subject Headings (MeSH) [30]. The lists of references in the retrieved publications were also used to make more enquiries.

Criteria for including and excluding publications

All the publications established through search engines listed above were assessed for relevancy. Criteria for inclusion included various economic evaluations [5]. Studies that compared KT, HD, and PD were prioritized for inclusion and those specifically evaluating the use of living donors and deceased donors in KT. Demographics and geographical location of where the studies were carried out were considered. All studies had to be written in English and previously carried out on dialysis and KT after 2000, with exceptional major studies before then.

As part of the exclusion criteria, editorials and letters were excluded with caution and used if necessary. Peer-reviewed literature was given priority, and some technical reports were also considered. Articles that did not compare economic evaluations of KT, HD, and PD were excluded. All studies written in a different language and dealing with other organ transplantation were excluded.

Study selection and data extraction strategy

The articles for review were extracted for the design of the study, research question, the economic evaluation applied, and study population besides, the design of the model used, measurement methods of utility values and the sources of the data, results of cost-effectiveness, and the conclusions. Consideration of the risk assessment methods used was also noted. All Consolidated Health Economic Evaluation Reporting Standards appraised research publications derived acceptance into the study [31]. The studies would have extensively applied the 24-item Consolidated Health Economic Evaluation Reporting Standards checklist to evaluate the descriptive nature and quality of economic evaluation [5],[31].

Quality check on study articles for validity of results

As this review will influence a national health policy change, most of the articles chosen performed probabilistic sensitivity analysis (PSA) and deterministic sensitivity analyses to investigate the effects of component variance on the outcomes of economic assessments [32].


  Results Top


From a search on four electronic databases, PubMed, Google Scholar, NHS EED, and Scopus, 277 articles were identified. Of these, 197 of the articles were excluded after title and abstract screening and in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Full-text review of the articles was done only after an evaluation of the titles and abstracts of the electronic citations. An additional 64 full-text articles that were outside the set criteria were also excluded. Of the 16 articles that fulfilled the specified criteria for inclusion as depicted in [Figure 1], five [5] were chosen using the Snowball method from references of the articles and reviews that were incorporated.
Figure 1 PRISMA flowchart for inclusion and exclusion criteria and review articles selection [26]. PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.

Click here to view


As part of the exclusion criteria, Scopus Database that has an analysis facility was used to create various categories of the search strategy [33].

Literature review characteristics

One of the primary aims of this study was to review studies in which a CEA would have been carried out in developed and developing countries between KT and dialysis. The strength and authenticity of the reviewed studies had to be based on economic evaluation tools, which would also justify the relevancy of transplantation in improving QOL. The outcome from this analysis would enable an assessment of the effectiveness in terms of the cost of transplantation compared with dialysis.

As shown in [Table 1], the countries where the research was carried out were listed, and the selection was based on their developed and developing status. An indication of the economic evaluation category was also noted. Markov economic evaluation models, public health perspective, societal perspective, third-party payer, and a check on the authenticity of the studies was also noted as PSA [5].
Table 1 Literature review characteristics and outcomes

Click here to view


In their prospective societal study in the Netherlands, de Wit et al. [21] carried out an economic evaluation of the CEA and CUA type based on clear-cut and incidental costs of RRT and life quality of 165 ESRD patients. The study was designed on the Markov model of 38 states for 5 years with a discounted rate of 5%. The breakdown of the states was as follows: mixture of therapy modes (hospital unit HD, private unit HD, residential facility dialysis, and KT), limited age groups of up to 65 years or more and unchanged therapeutic periods over at least 2 years, deceased, and renal function recovered. QOL was determined using EuroQol (EQ-5D), SG, and TTO [5],[25].

de Wit and colleagues ‘s research outcome, based on the QOL derived from EQ-5D, SG, and TTO methods, the general utility values of state of health ranking showed that KT had a higher state of health utility ranking of 0.90 followed by PD at 0.71 and lastly HD at 0.66.

At the cost of dutch florin (DFL) 133 000 for an improved expectation to survive using dialysis procedures and a corresponding QALY of DFL 190 000, dialysis is more expensive than KT, which is at the cost of DFL 25 000 for an improved expectation to survive and a corresponding QALY of DFL 27 800.

Finally, regarding the costs of treatment, they considered the direct and hidden costs covering general diagnostics, hospital admissions’ human resources costs, surgical procedures, medicines, machinery, accommodation utility bills, food costs, and commuting costs. The average yearly costs in year 1 for hospital HD was DFL 152 666; PD DFL 102 839; and KT DFL 90 000. In the second year, the costs were HD DFL 145 757; PD DFL 94 699; and KT DFL 18 000.

A third-party payer prospective study by Howard et al. [45] in Australia on ESRD patients during 2005–2010 conducted an economic evaluation of the CEA and CUA type on 168 participants. This Markov model was dynamic population based on four states enumerated as HD, preemptive KT, KT, and deceased with a 1-month length, plus a discount at 5% benefits and costs. The study’s goal was to evaluate the expenses and health impacts of potential improvements in health-care provision. Notably, Howard et al. [45] measured the cumulative national health risks and advantages of raising the number of additional CKD patients undergoing a KT to around 10–50% and expanding the number of additional home dialysis patients instead of hospital-based dialysis [45].

The origins of the utility values for the utility-based QOL years QALYs and life years gained were determined using TTO with the information source from studies conducted by Laupacis et al. [46].

The information relating to the costs of various products associated with dialysis and KT was gathered from various Australian Institutions. The costs reviewed were direct health-care products covering renal therapy technology infrastructure, repairs, human resources remuneration, dialysis sundries, medications, vascular access construction and revision, hospital admissions, reviews, KT initial tests and assessment, graft allocation, and transplant operation immunosuppression.

Using TTO, Howard and colleagues calculated utility values for KT as HD 0.55, PD 0.55, and KT 0.73, showing that KT had a higher utility value and state of health with PD and HD ranking low equally.

The yearly rise in KT to 10 and 50% by 2010 dominated the original HD formula of treatment. On average, the annual treatment costs were A$82 764 for HD, A$ 56 828 for PD, and A$ 70 553 for KT in the first year, which then went down to A$44 777 in the second year and A$39 599 in subsequent years.

Haller and colleagues designed a public health perspective Markov model of expenditure, QOL, and survival to correlate three Austrian RRTs. The model aimed to evaluate the spending per QALYs of the existing government policy against two newly proposed treatment formulas over 10 years. The first formula allowed for 20% of the CKD population to be apportioned to PD treatment. The second strategy allowed for 20% of recent cases to be assigned to PD and a further 10% receiving a living donor KT. The Markov model consisted of 10 states, each delineated to QOL and cost.

The information for the study was collected from Austrian health institutions and a health insurance company. The project looked at direct health-care costs discounted at 3%, encompassing imaging, renal therapy technology infrastructure, repairs, human resources remuneration, dialysis sundries, medications, vascular access construction and revision, hospital admissions, reviews, KT initial tests and assessment, graft allocation, organ harvesting, donor nephrectomy, transplant operation, and immunosuppression medicines.

The study considered the QOL, evaluated as QALYs.165 patients participated, and the assessment instruments applied were EuroQol, EQ-5D, SG, and TTO [5],[21],[25],[35].

In the assessment by Haller and colleagues, the first-year average transplantation cost was Euro 50 900, Euro 43 600 for HD, and Euro 25 900 for PD; in the second year Euro 40 000 for HD, Euro 15 300 for PD, and Euro 17 200 for KT; in the third year HD Euro 40 000, PD Euro 40 600, PD Euro 20 000, KT Euro 12 900.

This study’s survival rates showed an increased death rate in dialysis patients with HD at 2.21%, PD at 0.94%, and living donor KT having the lowest death rate at 0.08%.

The cost-effectiveness as measured for their current RRT practice was 259 731 life years discounted and 203 407 QALYs: 260 435 life years and 204 245 QALYs for the second strategy, and finally 26 151 for the third strategy and 205 648 QALYs.

Villa and colleagues carried out a CEA societal prospective study on the Spanish renal program employed a Markov model that covered three temporal horizons of 5, 10, and 15 years at a 3.5% discount rate with four states being HD, PD, KT, and death. While their study had scenarios mostly comparing HD and PD costs, they also compared them with KT costs and utilized utility values derived by other researchers [32]. SF-6D utility values were calculated using SF-36 to come up with QALYs. Clear-cut and incidental costs were identified, and ICER was estimated.

The state of affairs in 2012 was correlated with new schemes. The utility values used by Villa and colleagues were HD 0.69, PD 0.69, and KT 0.81. In all the scenarios presented in their study, the cost of transplantation and PD remained low. The cost values obtained without transition costs were around Euro 36 000 for HD, Euro 26 000 for PD, and Euro 11 000 for KT.

The QALYs per patient were on average 0.46 for HD 0.49 for PD and 0.61 for KT.

The ICER results showed that the method that was being used by the Spanish program in 2012 was dominated by the proposed methods, which saw a rise in the amount of patients on RRT modalities and PD patients ultimately being considered for KT [40].

To further crystallize the cost-effectiveness of KT over dialysis, Shimizu and colleagues of Japan set up a study to carry out the analysis by using QALY. Of interest, they measured the health expenditure per QALY for HD, PD, and KT variations by utilizing an 8-state Markov model analysis as has been used in other studies, where KT has been demonstrated to have a lower expenditure and a higher QALY than HD. The time frame for the study was set as 15 years with 1-year cycle lengths and a discounted rate on costs of 3%.

The information used to determine the utility values was from previous studies that had used EQ-5D and SG instruments.

Shimizu and colleagues compared increased KT rates against the original treatment modalities; the QALY for the original RRT formula was 3.544 against 4.128 for KT. The cost per QALY for the original RRT formula was 84 008 versus 70 581 for KT. The ICER for KT at 10 899 was dominant against RRT, meaning KT was less expensive and more cost-effective [37].

More and more studies have confirmed that KT is more cost-effective than other renal therapy modalities. Likewise, Jensen and colleagues in their public health prospective study in Denmark estimated the cost-effectiveness of KT over dialysis by using a Markov model on a Danish CKD population, which covered the appropriate parameters of KT and dialysis.

In this study by Jensen and colleagues, transplantation was dominant over dialysis with reduced costs. The cost per QALY for dialysis was DKK 1 032 934, while the cost per QALY for KT was DKK 810 516. KT had the superior outcome of 4.4 QALY in comparison to dialysis with 1.7 QALY. Through PSA, Jensen and colleagues showed that KT was the dominant intervention, and there was a 99.3% chance of it as a cost-effective process on a 0 DKK/QALY willingness to pay rate value and a 100% possibility at DKK 30 000.

The products and services costs were calculated as direct expenditure for therapy, reviews, nephrectomies, KT operation, and immunosuppression therapy.

ICER was evaluated using PSA [15].

QALYs were used as the measure for the effectiveness of the therapy, and utility was determined with the use of EQ-5D results from a study by Sennfält et al. [47].

Another third payer prospective study comparing cost-effectiveness between transplantation and dialysis in terms of QALYs was carried out by Rosselli and colleagues of Colombia. They used a Markov model of eight transitional states covering 5 years with one monthly cycle at a yearly discount rate of 3%. They collected information from worldwide registries and Tufts University database for utilities for the calculation of QALY values.

The annual yearly costs for Rosselli and colleagues amounted to US$ 76 718 for KT, and the preferred costs for dialysis was US$ 91 440; however, this figure was reduced to US$ 76 891 due to a high rise in deaths of patients in the dialysis group in the study.

The QALY for KT was higher than dialysis being 2.9832 and 2.1037, respectively.

The PSA revealed that in 76% of the tests, KT had higher cost-effectiveness than dialysis [43].

From a societal perspective, an economic evaluation study by Moradpour and colleagues investigated cost utility to assess expenditure plus performance levels among the CKD population of Iran. The study population consisted of 214 patients.

A 4-state Markov model to establish QALY was used based on a lifetime time horizon with monthly cycle lengths and a 6% discount rate. The states covered HD, PD, KT, and death.

The utility values used of 0.72 for HD, 0.75 for PD, and 0.82 for KT were extracted from the Persian version of Euro QoLEQ-5D-5L.

The expenditure and performances levels were taken from clear-cut and other incidental health costs. This information was availed from hospitals and personal interviews with patients.

The PSA for measuring the sensitivity of the model was performed.

While the initial costs for the three main parameters in the study by Moradpour and colleagues came out as HD US$ 13 477, PD US$12 865, and KT US$ 16 450, the KT had 9.43 QALY, PD 6.95, and HD 6.04.

At US$1744 per QALY gained, the average CE for the provision of KT was much less than PD, which was US$1850 per QALY gained and HD, which was also high at US$ 2227 per QALY gained. HD was dominated by PD while the KT against PD ICER was US$ 1446 per QALY.

The effectiveness of KT at the US$20 000 thresholds was high at a PSA probability of 76% [41].

A study whose objective was to find out the QALYs and expenditure for HD, PD, and KT in Greece was set up by Kontodimopoulos and Niakas.

The utility index was obtained from data collected from CKD patients divided into 642 HD patients, 65 PD patients, and 167 KT patients. The SF-6D scoring instrument was used to calculate utility scores, while information from the Association of the European Registries was used for the prediction of existing measures or life expectancy.

Lifelong QALYs for each participant was estimated at a 5% discounted rate. Items such as human resources bills, general operations costs, equipment, building maintenance, diagnostics, medicines, and sundries were considered for the study. KT costs were acquired from local transplantation reports.

In the study by Kontodimopoulos and Niakas, the mean utility for HD was 0.639, and for PD was 0.599, while KT was higher at 0.716. The lifelong QALY undiscounted stood at 16.11 QALYs for KT, 4.37 QALYs for HD, and 3.94 QALYs for PD.

The mean yearly expenditure was Euro 30 719 per patient for PD, Euro 36,247 for HD and for KT in the first year was Euro 31 714. At a 5% discounted rate, the lifelong treatment costs varied from Euro 200 728 for HD, Euro 167 853 for PD, and Euro 109 514 for KT.

The cost/QALY was calculated to Euro 11 981 for KT, Euro 54 504 for PD, and Euro 60 353 for HD [38].

In their prospective, descriptive study in Barcelona, Spain, Sanchez-Escurado et al. conducted a cost and efficacy comparative analysis of 57 HD patients and 49 living donor KT patients during the initial year of transplantation.

From the Sánchez-Escuredo and colleagues study, preoperation costs such as laboratory testing, scans, and all other related experiments were considered to calculate transplantation costs. The costs of the KT procedure, patient care for the first year after engraftment, immunosuppression medications, hospitalization, and evaluations were assessed.

The costs of human resources and infrastructure maintenance upkeep were calculated separately.

The HD cost annually was calculated by multiplying the price of each treatment by the quantity of HD treatment sessions annually.

The bill for prescriptions, hospital stays, the procedure of establishing or repairing vascular access, and ancillary expenditures were all part of the HD costs.

The QALYs had 0 assigned to it for death and 1 for good health. In the Sánchez-Escuredo and colleagues analysis, the measured score for their study group for HD was 0.57, and the estimated score for KT was 0.80.

This study determined the cost of living donor KT to be Euro 29 897 in the first year. The donor costs were Euro 8128.44 and Euro 21 769.47 for the recipient. The HD cost was Euro 43 000 per year. In terms of life quality, KT had higher QALYs against HD, which had a low QALY irrespective of being more expensive. By having KT, each patient saved Euro 13 102 per year [36].

The Perovic and Jankovic study in Serbia involved 150 ESRD patients, of which 50 were KT patients and 100 were HD patients. They carried out a CEA on the patients.

The study of Perovic and Jankovic took into effect the direct and indirect costs related to the provision of service to KT and HD patients. The impact of organ transplantation on HD as a treatment option was interpreted as a cumulative proportion of benefits and costs (ICER).

The study also verified the QOL between the two groups and the sum of survival years was defined as QALYs.

The study concluded a significantly better life quality in KT patients (68%) than HD patients (43%).

The costs determined by the study for HD were Euro 165 334.50 per year and a QALY of 4.83. The CE ratio is Euro 34 230.75. The price for KT was Euro 48 949.00 per year and a QALY of 5.71. The CE ratio was Euro 132 265.25, showing that KT management was much lower than HD [39].

Silva and colleagues compared the direct and indirect costs of individual RRTs, including deceased donor KT and living donor KT. They made cost comparisons for HD and cadaveric kidney donor KT, HD and LDKT, PD and DCD KT, and PD and LDKT over 4 years. Their study was based on literature data and a private hospital in Rio de Janeiro, Brazil.

Silva and colleagues made cost comparisons between HD and DCD KT, HD and LDKT, PD and DCD KT, and PD and LDKT over 4 years.

The study considered the costs of the various modalities of RRT and also for cadaveric and living transplantation. The price of HD was calculated to be R$34 800 annually. A comparative analysis between cadaveric transplantation and HD showed that the price of KT is high in the initial year ranging between R$ 36 781 and R$ 78 000. This high cost is due to the operation and sundries and immunosuppressive medicines. Generally, the cadaveric KT costs tapper off to an annual cumulative average of R$ 8000 until the fourth year posttransplantation, while the time when the costs equalize is 32 months posttransplant operation. After a 4-year follow-up, their study showed that at least R$37 000 was preserved per patient in favor of KT.

Equally, for living KT and HD, the level of costs for candidates receiving a living donor kidney starts at R$28 300, which is a higher level than PD patients. Likewise, the raised costs are due to the renal transplant operation, sundries, and immunosuppressive medicines. Generally, as with the cadaveric donor KT, the living donor KT costs tapper off to an annual cumulative average of R$ 8000 until the fourth year posttransplantation, while the time when the costs equalize is 28 months posttransplant operation. After a 4-year follow-up, their study showed that at least R$45 6000 was preserved per patient in favor of transplantation.

In the comparison in costs for cadaveric donor KT and PD, in their study Silva and colleagues found that in Brazil the annual cost for PD was around R$44 000 and higher than the price of KT. The results showed that the costs between cadaveric donor KT and PD equalize at 24 months posttransplant operation. Their study after a 4-year follow up showed that at least R$73 700 was preserved per patient in favor of KT [42].

For living donor renal transplantation and PD, in their study Silva and colleagues found that the costs between living donor KT and PD equalize at 21-month posttransplant operation. Their study after a 4-year follow-up showed that at least R$82 300 was preserved per patient in favor of KT.

Kaminota in his study in Japan made comparisons in terms of cost-effectiveness of KT and HD based on longevity and life quality of the patients in the study groups by using DALYs, which are a commonly used method for identifying disease burden [1].

In Kaminota’s [34] study, dialysis prevented around 138 000 DALYs annually and a C-E ratio of Yen 9456, LDKT prevented 5740 DALYs annually and a C-E ratio of Yen 1809, and cadaveric KT prevented 1892 DALYs annually with a C-E ratio of Yen 2322.

Makhele and colleagues carried out a prospective study where they observed and analyzed data from 46 ESRD patients undergoing HD and PD treatments at a South African academic medical center. They reviewed the health-care provider costs categorized as initial maintenance. The cost of equipment and repair was classified as fixed, while costs of drugs, renal solutions, pathology tests, disposable sundries, power, and water usage were classified as variables. They also took into consideration human resource remuneration.

From Makhele et al. [44] in their study established that the yearly expenditure of around US$ 32 000 to provide HD was higher than that of PD at around US$ 25 000.

Other studies in South Africa have reported the number of KTs in 2016 to be 254 [52].

The UK National Health Services Blood and Transplant Fact Sheet no 7 of 2008 confirms that KT is the most preferred therapy for patients with ESRD in the UK. The established costs per patient for HD are GBP 35 000 per year and GBP 17 500 per patient per year for PD, while the cost per transplant per year was GBP 25 800 in 2008. At the time of their report, the total ESRD patient population was 37 800 and the renal budget consumed 3% of the UK NHS budget [48].

Yang et al. [5] carried out a review of 10 studies, which covered economic evaluation of all types of RRTs. These were model-based studies carried out from public health-care, societal, and third-party payer perspectives. Their review showed all the parameters for QOL and cost utilities to be in favor of KT.

The current cost estimates for the provision of HD in Zimbabwe are estimated to be US$ 33 000. The costs of Zimbabwean renal patients accessing foreign KT in India is, on average, estimated to be US$ 25 000 inclusive of patient and living donor airfares, hotel, and food costs while abroad. The cost of the same in South Africa is around US$19 000.

Outcomes on cost utility economic advantages, and quality of life assessments

The de Wit and colleagues study is a clear testimony of the benefits of utilizing KT more than maintaining patients on dialysis procedures, which are costly. The study has also shown that PD is also a relatively cost-effective mode of treatment than HD. For Netherlands the study also created an opportunity for the establishment of home-based PD and HD as well as private HD all of which are cheaper than hospital-based HD although still more expensive than KT.

Howard and colleagues’s scenario of expanding the amount of KT from 10 to 50% by 2010 culminated in reduced rates and better survival and quality-adjusted sustainability. To put it another way, raising the grafting volume was less costly and far more successful by contributing to higher LYS and QALYs than the existing renal care modalities.

The study by Haller and colleagues demonstrated that KT and PD are better systems than HD and a combination of PD and HD will result in a cheaper outcome.

The results from the Villa and colleagues analysis showed a cost-effective outcome between KT, which had a higher utility value of 0.81 and the other two modalities, HD and PD, which were both at 0.69 utility value.

Shimizu and colleagues concluded that having higher numbers of CKD patients on KT referred from an increased number of PD patients yields to lower expenditure coupled with a higher level of health results.

Jensen and colleagues’s results indicate that KT should be given a higher preference than dialysis due to its low costs.

The accumulative amount per QALY, when taken into effect, displays KT as the favorite alternative to dialysis.

Rosselli and colleagues concluded by encouraging KT for CKD patients instead of dialysis.

The Moradpour and colleagues study, like other studies, also proved that KT is more cost-effective than HD.

As predicted in the study of Kontodimopoulos and Niakas, HD had a greater premium for each QALY, precisely 10.7% greater over PD and 32.6% greater over KT in the initial year. The disparity between HD and PD was due to HD’s more considerable lifetime expenses, as the two techniques were observed to be roughly equal in terms of the amount of lifetime QALYs generated.

As established by the Kaminota study, Shimizu and colleagues proved that it was logical from the cost analysis for Japan to increase KT availability to CKD cases.

The findings of Yang and colleagues confirmed KT to be a more economical treatment for ESRD than dialysis.

Sánchez-Escuredo and colleagues indicated the government of Spain’s prohibition of donor remuneration. Their study proved that KT is cheaper than HD and represented a saving of Euro 13 102.97 for each patient yearly, with a better QOL.

Likewise, Perovic and Jankovic demonstrated that KT is cheaper than HD. The KT technique is therefore much more successful, representing a gain of Euro 132 256.25 annually. Serbia has a shortage of relevantly trained staff and equipment and has only 12.3% of their patients on KT compared with a large number being on HD and PD. The authors called for an improvement in KTs in Serbia, and this study supported their call. They outlined an extensive plan that will see the training of additional medical staff, ensuring relevant legal instruments are in place, and donor mobilization plans and public awareness and acceptance of organ donor cards.

Cost-effectiveness studies in the United States have shown that the KT costs are USD 7460.00, USD 12 100 for home HD, and USD 33 300.00 for hospital HD [17].

Silva and colleagues results in Brazil showed that, in general, KT is cheaper than HD and PD. They further proved that living donor KT is less expensive over time irrespective of the initial high costs of the transplant operation and immunosuppression medicines.

At the time of the study, Brazil was experiencing a lack of kidney donations, and the significant negative factors were disapproval to donate kidneys by family members, culture, and religion.

The Kaminota study demonstrated the cost-effectiveness of KT over dialysis and encouraged the Japanese government to shift focus toward increasing KT.

Makhele and colleagues showed that HD cost was higher than PD in South Africa. In other studies, the cost of KT in South Africa has been indicated to be lower than HD.

The NHS Blood and Transplant UK established that KT had saved the NHS UK GBP 50.3 million per year in 2008 in dialysis costs. With the number of KT transplants going up to 23 000 in 2009, the cost-saving went up to GBP 512 million. The United Kingdom continues to increase the number of KT to save money.

Cost utility, economic advantages, and quality of life

Most researchers found that KT was by far an economically advantageous RRT treatment option across the board, with PD outperforming HD [5]. Many research studies concluded that KT was superior to HD and PD in terms of reduced costs, increased efficacy, and a better QOL.


  Discussion Top


One of the aims of this study was to look at research studies that used methods like the Markov model and CUA to explain the relevance of KT in raising the health status, wellness level, good living, and survival rate of ESRD patients at a lower expenditure.

Much model-based analysis used in this review used these economic evaluation tools, showing that such studies thought these methods adequately describe CKD. This is, therefore, in line with the aims of this study. Authentication of the information to support the review’s aims was based on the use of PSA and deterministic sensitivity analyses in most of the studies reviewed. In general, therefore, the outcomes of this review can be relied upon as a basis for introducing new health policies.

Ultimately, the data from this review suggests that dialysis is less effective costwise than KT, which is a superior form of treatment [5]. While the prices and health implications for every report are country-specific, the comparable rates and efficacy of KT versus dialysis therapies are consistent throughout the various articles reviewed. Furthermore, the bulk of included research shows that HD is more expensive than PD. PD, however, has equivalent or improved results [5]. It was also quite clear that the more the KT operations performed, the higher the overall savings in the RRT budget.

As per the aims of this study, a review of the costs of RRT in a developing country neighboring Zimbabwe has also shown that KT is cheaper than HD and PD in South Africa. The costs for Zimbabweans accessing KT in South Africa are higher due to additional expenses of patient and donor airfares, hotel and food costs for accompanying relatives and the living related donor.

Comparison of the option of kidney transplantation with dialysis

When CKD cases reach end-stage renal failure and become symptomatic, they will require to be placed on dialysis. There are two main kinds of treatment applied when kidney failure sets in. These are KT and dialysis. Dialysis is composed of peritoneal and HD. In PD, a robust salt solution is left to dwell for several hours while the exchange of molecules occurs across the peritoneum membrane through ultrafiltration and diffusion before being drained, and another cycle commenced with fresh dialysate. For CAPD, exchanges are done over 24 h at 4-h intervals and an overnight exchange lasting 8 h. For APD, the exchanges are automated and done overnight.

HD uses a dialysis machine to pump blood from the patient through vascular access and introduces it into a dialyzer made up of semipermeable membrane and immersed in a dialysate solution of a specified composition. The dialyzer is designed so that the blood will not come in contact with the dialysate, but its impurities will be filtered through the membrane to the dialysate side, which will then be drained to a single pass system.

While dialysis can save lives, KT has superior outcomes among the various treatment modalities of ESRD. However, due to limited donations, dialysis becomes relevant for those patients who cannot get kidneys for transplantation.

There is solid proof that people with a KT have higher rates of survival, are unlikely to be hospitalized due to a lower risk of infection, in contrast to the significant risk of infection connected to the vascular and peritoneal access needed for dialysis treatment. The chances of KT recipients having so many problems that are usually associated with dialysis are minimized. For instance, dialysis patients are confined to strict dietary control and fluid intake and have the inconvenience of attending remote dialysis centers. An effective KT might be a blessing of freedom from dialysis equipment and reliance upon everyone else. Furthermore, KT recipients have substantially fewer cardiovascular complications than patients on dialysis treatment [49].

Relief is realistic for the kidney recipient from these stringent conditions and inconveniences as they can resume their daily routines and have uninterrupted movement.

The usual fear with KT is rejection; however, there is now minimal rejection with the invention of new immunosuppressive regimens.

As already alluded, KT is shown in several studies to be a cheaper treatment option than dialysis and offer improved quality and quantity of life than dialysis, which is the most valuable advantage of KT [50]. The general QALY score for KT is 0.74 out of 1, while the QALY score for dialysis is lower at 0.55 out of 1 [14].

Barriers to transplantation in Zimbabwe and solutions to promote kidney transplantation in Zimbabwe

The current dialysis program in Zimbabwe consists of HD (95%) and PD (5%). Dialysis in public health institutions is provided for free while the private centers charge. Zimbabwe is a low-income country, and the rate of dialysis is 29% per million population [51]. The activities of the renal program in Zimbabwe can be divided into three categories.

First, treatment of patients with potentially reversible renal failure. Such acute kidney disease may affect patients with severe malaria, other severe infections after trauma or major surgery, after ingestion of traditional drugs or other toxic substances. These patients need short-term (1–6 weeks) support with dialysis, while a healing process occurs in the kidneys.

Second, treatment of patients with chronically progressive kidney disease leading to chronic, irreversible renal failure. Such disease may be due to inflammatory or infectious disorders or inherited degenerative processes. High blood pressure, which is the cause of ∼33% of all instances of ESRD in Zimbabwe, has been linked to significant renal deaths. Other causes include diabetes mellitus, herbal intoxication, glomerulonephritis, and schistosomiasis-related occlusion. These patients need lifelong treatment with dialysis.

The third category is the treatment of specific groups of patients with or without kidney disease where the equipment of dialysis may be utilized, for example, severe intoxications, which may be treated with hemoperfusion.

While a transplant program was initiated in 1992, this has however not been active. There is currently no exit for patients on dialysis except through receiving transplants abroad at high costs, which are met by families and, in some cases, with some support from the medical insurance companies. The problem with foreign KT is the lack of proper follow-up of the recipients and donors on return from the countries where the operation would have been done.

The government’s current policy is to meet the full costs for dialysis and provide the foreign currency through the Reserve Bank of Zimbabwe for all patients, who travel to receive KT abroad. This foreign transplantation element, which entails hospitalization abroad for the donor and recipient and hotel fees for an additional relative, is consuming excessive funds that could create an effective KT program if utilized locally. It also just benefits a few well-to-do patients and neglects the socially disadvantaged majority.

With the outcome of this review demonstrating that KT is a less costly procedure than dialysis and all the benefits that come with it, the necessity to reintroduce KT in Zimbabwe becomes critical. However, some key issues would need to be put in place to remove the barriers. There is a shortage of skilled workforce to provide the necessary care to the ESRD patients and the lack of training programs in KT surgery and postoperative care for doctors, nurses, pharmacists, and scientists. The current dialysis program itself will need further upgrading to match the envisaged modernized transplantation program and create a safe fallback position for those patients who will need to be referred to dialysis in the unlikely event of graft rejection.

There is a need for community education aimed at awareness and acceptance of KT and donation of organs.

Preventative measures against CKD need to be stepped up with the commencement of an intensive preventative/early treatment and education program for the presently known causes of renal failure: hypertension, diabetes mellitus, schistosomiasis, and herbal toxicity.

A renal registry would need to be set up to capture epidemiological data regarding the incidences and severity of these causes and transplantation data. There is, therefore, a need to strengthen the management and coordination of the program.

A partnership with a foreign institution of higher learning and a hospital that is already involved in KT would need to be established to kickstart the program. Similar partnerships have been successfully set up in other areas of health.

The first KT operation was carried out in 1992, and another updated unit with the relevant infrastructure is available for use.

The government’s thrust is to see an improved health delivery system in Zimbabwe. However, it is widely accepted that a significant impediment to this drive is the lack of adequate funding. However, it is interesting to see how a lack of appropriate finance has molded the health-care public–private partnership debate. The public–private partnership model is in keeping with national and global developments, and it will help the country strengthen its medical facilities and service delivery.

The collaborative regulatory framework is now at the heart of the leadership’s desire to achieve because it will be consistent with the state’s concept of implementing good medical services.

The collaboration will establish a strong, profitable scenario where both players are guaranteed to equally benefit, thus greatly improving patient care, and upgrading the center’s capability into a global player in KT.

On the one hand, the government guarantees to provide an enabling environment for the private partner to get a return on its investments through revenue collected from the activities.

The government’s key objective is that socially disadvantaged patients will receive treatment without any prejudice and that legal compliance of the partnership process is adhered to.

A memorandum of understanding can be drawn with a framework and joint technical cooperation, respective mandates, and work-related programs in developing a KT program at an identified center in Zimbabwe.

The government’s primary responsibilities would be to provide all the relevant infrastructure and bring up to the standard the intensive care unit, theaters and posttransplant wards, dialysis units, laboratory, pharmacy, and radiology services. The commercial operator can oversee efforts to rebuild the facilities and ensure that the latest equipment is purchased to ensure that all the center’s sections are entirely operational.

On the other hand, the external partner would assure the deployment of appropriately qualified staff at the transplant center, comprising all categories of specialists, and the government will facilitate the issuance of the practicing licenses of these specialists. Likewise, the government will also identify local medical and nursing professionals for training under the transplant program who will be a part of the initial transplant team performing KT at the center in the future after training. The local staff will work under training from the external partner.

The center and the external partner shall enter into a technology transfer agreement on various areas of KT. This arrangement will see transplant patients are catered to by the center to be managed for preoperative evaluation and posttransplant management. The capacity building and knowledge transfer initiatives will help develop a full-fledged transplant program at the center in the coming years.

The external partner will coordinate the KT program establishment with the Zimbabwean staff understudying in the initial phase. This coordination will include a review of the available technology and resources before the start of the program, especially the availability of immunosuppressive and other drugs required for patient management. The project will be rolled out in a phased manner, and all rates will be mutually agreed upon and subject to approvals from the Government of Zimbabwe.

Therefore, of utmost importance is the allocation of kickstart funds from the Treasury to be able to meet the training costs, buy all the equipment, immunosuppression medicines, diagnostic testing kits, and all ancillaries required. Just as has been done for the dialysis, Treasury could also consider covering the costs for the locally performed transplant operations, including remuneration and benefits for the donor.

The final solution to ensure the viability of the transplant program is by introducing Universal Health Coverage through the setting up of the National Health Insurance that provides a basic benefits package to the entire population of Zimbabwe mainly financed by a combination of state funds social contributions (prepayments). This will establish an integrated health system that will increase available resources for the renal program and the health sector in general.


  Conclusion Top


This literature review has addressed all the initial aims it set out to answer. The evidence of research on the economic advantages and QOL of KT against dialysis, as demonstrated by this review, has significant effects on establishing a full-fledged KT program in Zimbabwe. The barriers to transplantation in Zimbabwe have been identified, and the solutions for coming up with a fully composite implementation strategy enumerated.


  Limitations Top


While the most critical outcome was that KT was the best option, the information utilized to arrive at this conclusion was variable in most studies and did not follow a standard checklist of product costs. In terms of utility values, some studies used values from retrospective research. The comparison across articles was therefore not optimized.


  Further research Top


The evidence of economic advantages, CUA, and QOL on RRTs in Zimbabwe, neighboring countries, and the majority of low-to-middle-income countries is scarce in the literature. It is, therefore, relevant for further studies to be carried out in this respect.

Financial support and sponsorship

Nil.Conflicts of interest

There are no conflicts of interest.



 
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