A Cost-Effectiveness Decision Analysis of Living Donor Liver Transplantation

Background: Liver transplantation is considered the standard of care treatment for end stage liver disease and cirrhosis. Because of the sizable waiting list and relatively long waiting times over the past few years in the U.S., donation of a portion of liver from a living donor has arisen as an alternative to deceased donor organ allocation. The LDLT shortens recipient time on the waiting list but has significant risks to the living donor. This study is a cost-effectiveness analysis designed to explore the costs and benefits of adding LDLT to the treatment of end stage liver disease. Methods: A complex Markov decision analysis model was developed to simulate all of the important events in the course of cirrhosis. Treatment strategies including no transplantation, DDLT-only, LDLT-only, or combined DDLT/LDLT were investigated using a Monte Carlo cohort analysis and expected value calculations to determine cost effectiveness. A sensitivity analysis was performed to determine variables important to the model. Results: Demonstrating good external validity, using the base-case values, the model produced raw survival rates and event occurrence rates similar to those published in the literature. Baseline cirrhosis offered 2.0 QALY survival while costing $17,000, DDLT-only offered 4.1 QALY survival and cost $121,000, LDLTonly offered 3.8 QALY survival and cost $143,000, and combined DDLT/LDLT offered 4.4 QALY survival and cost $162,000. The LDLT-only strategy was dominated. The DDLT-only strategy had an ICER of $49,920 over no transplant while combined DDLT/LDLT had an ICER of $129,474 over DDLT-only. The ii sensitivity analysis showed the model to be sensitive to the rate of donor death, the cost of the actual transplant procedures, and the rate of post-transplant recurrent disease causing graft failure. Conclusions: DDLT is a cost-effective treatment strategy for end-stage liver disease. The addition of LDLT to the treatment paradigm offers slightly longer quality adjusted survival at much greater cost. Society, third party payers, and government agencies will eventually be forced to determine the willingness to pay for the various treatment strategies for end-stage liver disease. More studies are needed to clearly define the risks and benefits of this controversial procedure.

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