De Novo Donor‐Specific Human Leukocyte Antigen Antibody Screening in Kidney Transplant Recipients After the First Year Posttransplantation: A Medical Decision Analysis

• Published in: American journal of transplantation Vol. 16; no. 11; pp. 3212 - 3219
• Main Authors: Kiberd, B. A., Miller, A., Martin, S., Tennankore, K. K.
• Format: Journal Article
• Language: English
• Published: United States Wiley Subscription Services, Inc 01.11.2016
• Subjects: Antibodies; clinical research/practice; Death; Decision Support Techniques; Follow-Up Studies; Glomerular Filtration Rate; Graft Rejection - diagnosis; Graft Rejection - etiology; Graft Survival; health services and outcomes research; Histocompatibility antigen HLA; HLA Antigens - immunology; Humans; Immunosuppression; Isoantibodies - analysis; Isoantibodies - immunology; kidney disease: immune/inflammatory; Kidney Failure, Chronic - immunology; Kidney Failure, Chronic - surgery; Kidney Function Tests; Kidney transplantation; Kidney Transplantation - adverse effects; kidney transplantation/nephrology; Kidney transplants; Mortality; Postoperative Complications; Prognosis; Prospective Studies; quality of life (QOL); rejection: antibody‐mediated (ABMR); risk assessment/risk stratification; Risk Factors; simulation; Survival; Tissue Donors; Transplant Recipients; risk assessment/risk stratification; quality of life (QOL); kidney disease: immune/inflammatory; clinical research/practice; kidney transplantation/nephrology; rejection: antibody-mediated (ABMR); simulation; health services and outcomes research
• ISSN: 1600-6135; 1600-6143
• DOI: 10.1111/ajt.13838

Screening for de novo donor‐specific antibodies (dnDSA) in stable kidney transplant recipients is routine practice in some centers. Patients with DSA are at increased risk of graft loss and early intervention may improve outcomes. However, the costs and benefits of dnDSA surveillance are unknown. A medical decision analysis to examine a screening strategy was developed for kidney transplant recipients who had stable graft function and were DSA negative 1 year posttransplant. In the base case, a modest 25% reduction in graft loss in dnDSA–positive patients treated with increased immunosuppression resulted in 0.04618 quality‐adjusted years (QALYs) gained. However, benefits from reduced graft loss were eliminated if there was a small increased risk of death from added therapy. The incremental cost effectiveness was marginal at approximately $120 000–250 000 per QALY, but could be more or less favorable depending on several key variables such as efficacy of treatment, screening costs, incidence rate of subclinical dnDSA, and patient survival. Screening performed the best in patients with lower mortality rates and higher baseline incidence rates of dnDSA. Further study is warranted to gather the necessary high‐quality evidence to justify screening. The authors examine the potential benefit, harm and cost of screening for de novo donor‐specific antibodies (dnDSA) in stable kidney transplant recipients 1 year posttransplant and find that the cost‐effectiveness of screening depends on finding safe, effective therapies and targeting younger patients at higher risk of dnDSA.