TWO-HOUR POST-DOSE CYCLOSPORINE LEVELS IN RENAL TRANSPLANTATION IN ARGENTINA: A COST-EFFECTIVE STRATEGY FOR REDUCING ACUTE REJECTION

P881 Aims: Monitoring of cyclosporine (microemulsion CsA) at 2 hours post-dose levels (C2) is an accurate measure of CsA absorption efficiency and exposure, and appears superior to trough (C0) monitoring for prediction of rejection risk. The purpose of this study was to determine if C2 was a cost-effective alternative as compared to trough monitoring in Argentina. Methods: A predictive decision model originally developed for Canada was adapted to Argentina to predict costs associated with C0 and C2 monitoring in the first 12 months after transplantation. Parameter estimates for key clinical events in the C2 strategy were derived from a randomized trial conducted in 30 centers in 10 countries. Patients were treated with microemulsion CsA, steroids and azathioprine or MMF. Parameter estimates for the C0 strategy were based on event rates observed in Canadian studies and published clinical trials. The model was adapted to the Argentinean health system through local protocols and expert opinions; costs were valued in December 2002 Argentinean pesos and converted to US dollars (1 USD = 2.85 ARS). The analysis was performed from the perspective of the health care payer. Results: The incidence of acute rejection was predicted to be 19.0% at 1-year in patients monitored by C0 and 13.8% in those monitored by C2. Graft survival was predicted to be 1.4% lower in the C0 group, while there was no difference in patient survival. The clinical data suggested no important differences in co-morbidity, in the costs of C0 and C2 monitoring, and in ambulatory-based adverse events between the C0 and C2 cohorts. The model predicted an average cost per patient for the first year post-transplant of $17,323 for C0 monitoring and $17,343 for C2 monitoring. The predicted cost for initial hospitalization was $6,912 for C0 and C2 monitoring. The cost of maintenance, graft loss and dialysis was $5,384 in the C0 cohort and $5,457 in the C2 cohort. Follow-up hospitalization consumed an additional $3,225 for each group. Treatment of acute rejection consumed $238 in C0 patients and $172 in those monitored by C2. Sensitivity analyses indicated that the average daily dose of microemulsion CsA was the most influential parameter affecting the incremental cost per patient. The next most influential parameter was the incremental probability of graft survival in the C2 cohort relative to the C0 cohort. Conclusions: In Argentina, C2 monitoring is expected to provide a potentially important reduction in the risks of acute rejection, and it does so without increasing the estimated cost of care in the first year post-transplant. Though modeling assumptions become more restrictive over time, this projection allows a preliminary assessment of the economic impact of the routine use of C2 monitoring.

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