Display options
Cite
Puttarajappa CM, Hariharan S, Smith KJ. A Markov Analysis of Screening for Late-Onset Cytomegalovirus Disease in Cytomegalovirus High-Risk Kidney Transplant Recipients. Clin J Am Soc Nephrol. 2017;13(2):290-298doi: 10.2215/CJN.05080517.
Puttarajappa, C. M., Hariharan, S., & Smith, K. J. (2018). A Markov Analysis of Screening for Late-Onset Cytomegalovirus Disease in Cytomegalovirus High-Risk Kidney Transplant Recipients. Clinical journal of the American Society of Nephrology : CJASN, 13(2), 290-298. https://doi.org/10.2215/CJN.05080517
Puttarajappa, Chethan M, et al. "A Markov Analysis of Screening for Late-Onset Cytomegalovirus Disease in Cytomegalovirus High-Risk Kidney Transplant Recipients." Clinical journal of the American Society of Nephrology : CJASN vol. 13,2 (2018): 290-298. doi: https://doi.org/10.2215/CJN.05080517
Puttarajappa CM, Hariharan S, Smith KJ. A Markov Analysis of Screening for Late-Onset Cytomegalovirus Disease in Cytomegalovirus High-Risk Kidney Transplant Recipients. Clin J Am Soc Nephrol. 2018 Feb 07;13(2):290-298. doi: 10.2215/CJN.05080517. Epub 2017 Oct 12. PMID: 29025787; PMCID: PMC5967425.
Copy Download .nbib Format: NLM
Share it on

Clin J Am Soc Nephrol. 2018 Feb 07;13(2):290-298. doi: 10.2215/CJN.05080517. Epub 2017 Oct 12.

A Markov Analysis of Screening for Late-Onset Cytomegalovirus Disease in Cytomegalovirus High-Risk Kidney Transplant Recipients.

Clinical journal of the American Society of Nephrology : CJASN

Chethan M Puttarajappa, Sundaram Hariharan, Kenneth J Smith

Affiliations

  1. Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania; and [email protected].
  2. Renal-Electrolyte Division, Department of Medicine and.
  3. Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania; and.
  4. Department of Medicine, Section of Decision Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania.

PMID: 29025787 PMCID: PMC5967425 DOI: 10.2215/CJN.05080517

Abstract

BACKGROUND AND OBJECTIVES: Management strategies are unclear for late-onset cytomegalovirus infection occurring beyond 6 months of antiviral prophylaxis in cytomegalovirus high-risk (cytomegalovirus IgG positive to cytomegalovirus IgG negative) kidney transplant recipients. Hybrid strategies (prophylaxis followed by screening) have been investigated but with inconclusive results. There are clinical and potential cost benefits of preventing cytomegalovirus-related hospitalizations and associated increased risks of patient and graft failure. We used decision analysis to evaluate the utility of postprophylaxis screening for late-onset cytomegalovirus infection.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used the Markov decision analysis model incorporating costs and utilities for various cytomegalovirus clinical states (asymptomatic cytomegalovirus, mild cytomegalovirus infection, and cytomegalovirus infection necessitating hospitalization) to estimate cost-effectiveness of postprophylaxis cytomegalovirus screening strategies. Five strategies were compared: no screening and screening at 1-, 2-, 3-, or 4-week intervals. Progression to severe cytomegalovirus infection was modeled on cytomegalovirus replication kinetics. Incremental cost-effectiveness ratios were calculated as a ratio of cost difference between two strategies to difference in quality-adjusted life-years starting with the low-cost strategy. One-way and probabilistic sensitivity analyses were performed to test model's robustness.

RESULTS: There was an incremental gain in quality-adjusted life-years with increasing screening frequency. Incremental cost-effectiveness ratios were $783 per quality-adjusted life-year (every 4 weeks over no screening), $1861 per quality-adjusted life-year (every 3 weeks over every 4 weeks), $10,947 per quality-adjusted life-year (every 2 weeks over every 3 weeks), and $197,086 per quality-adjusted life-year (weekly over every 2 weeks). Findings were sensitive to screening cost, cost of hospitalization, postprophylaxis cytomegalovirus incidence, and graft loss after cytomegalovirus infection. No screening was favored when willingness to pay threshold was <$14,000 per quality-adjusted life-year, whereas screening weekly was favored when willingness to pay threshold was >$185,000 per quality-adjusted life-year. Screening every 2 weeks was the dominant strategy between willingness to pay range of $14,000-$185,000 per quality-adjusted life-year.

CONCLUSIONS: In cytomegalovirus high-risk kidney transplant recipients, compared with no screening, screening for postprophylactic cytomegalovirus viremia is associated with gains in quality-adjusted life-years and seems to be cost effective. A strategy of screening every 2 weeks was the most cost-effective strategy across a wide range of willingness to pay thresholds.

Copyright © 2018 by the American Society of Nephrology.

Keywords: Antiviral Agents; Cost-Benefit Analysis; Cytomegalovirus Infections; Decision Support Techniques; Decision analysis; Hybrid strategy; Immunoglobulin G; Incidence; Kinetics; Quality-Adjusted Life Years; Screening; Viremia; cytomegalovirus; high-risk; hospitalization; kidney transplantation

References

  1. EBioMedicine. 2015 May 08;2(7):699-705 - PubMed
  2. Clin Infect Dis. 2008 Mar 15;46(6):840-6 - PubMed
  3. Lancet. 2000 Jun 10;355(9220):2032-6 - PubMed
  4. Am J Transplant. 2010 May;10 (5):1228-37 - PubMed
  5. Am J Transplant. 2004 Apr;4(4):611-20 - PubMed
  6. J Infect Dis. 2002 Jun 15;185(12):1723-8 - PubMed
  7. Clin Microbiol Rev. 2013 Oct;26(4):703-27 - PubMed
  8. Antivir Ther. 2017;22(6):503-513 - PubMed
  9. Transplantation. 2008 Nov 15;86(9):1323-4 - PubMed
  10. N Engl J Med. 2014 Aug 28;371(9):796-7 - PubMed
  11. J Am Soc Nephrol. 2009 Nov;20(11):2449-58 - PubMed
  12. Clin Infect Dis. 2013 Mar;56(6):817-24 - PubMed
  13. Clin Transplant. 2016 Sep;30(9):1159-64 - PubMed
  14. Clin Infect Dis. 2013 Dec;57(11):1550-9 - PubMed
  15. J Exp Med. 1999 Jul 19;190(2):177-82 - PubMed
  16. Transplantation. 2011 Jan 27;91(2):251-5 - PubMed
  17. Transplantation. 2013 Aug 27;96(4):333-60 - PubMed
  18. Am J Transplant. 2011 Sep;11(9):1936-42 - PubMed
  19. Transplantation. 2014 Jul 27;98(2):187-94 - PubMed
  20. Am J Transplant. 2010 Sep;10 (9):2026-32 - PubMed
  21. Transplantation. 2010 Feb 15;89(3):320-6 - PubMed
  22. Am J Transplant. 2016 Aug;16(8):2384-94 - PubMed
  23. Clin Transplant. 2008 Mar-Apr;22(2):222-8 - PubMed
  24. Transplantation. 2011 Nov 15;92 (9):1063-8 - PubMed
  25. Am J Transplant. 2012 Sep;12(9):2457-64 - PubMed
  26. Kidney Int. 1996 Jul;50(1):235-42 - PubMed

Substances

MeSH terms

Publication Types