Timing of parathyroidectomy after kidney transplantation: A cost-effectiveness analysis.

Introduction: Parathyroidectomy is the definitive treatment for tertiary hyperparathyroidism post-kidney transplantation. However, cinacalcet-based medical management is increasingly used as an alternative. The financial consequences of each treatment remain unclear. We aimed to identify the most cost-effective strategy for managing hyperparathyroidism from the kidney transplantation recipient's perspective.

Methods: We constructed a patient-level discrete event simulation model to compare parathyroidectomy and cinacalcet-based medical management. The effects of hyperparathyroidism on allograft survival and all-cause mortality were considered in the discrete event simulation model with a time horizon of 15 years. Our base case was a 55-year-old kidney transplantation recipient with persistent hyperparathyroidism and hypercalcemia. The primary outcome was the cost-effectiveness measured by cost per quality-adjusted life years.

Results: The monthly out-of-pocket cost of cinacalcet ranged from $12 to $288, depending on insurance coverage, with a base case cost of $150. Our base case analysis showed that parathyroidectomy was the dominant treatment with lesser cost ($1,315 vs $7,147) and greater effectiveness (3.17 quality-adjusted life years and 2.92 quality-adjusted life years) than cinacalcet. One-way sensitivity analysis on the cinacalcet treatment duration showed that parathyroidectomy became more cost-effective at 9 months. Two-way sensitivity analysis on the cost of cinacalcet and the duration of treatment with cinacalcet showed that as the monthly cost of cinacalcet increases, the expense of cinacalcet-based medical management quickly exceeds the cost of parathyroidectomy.

Conclusion: Parathyroidectomy becomes more cost-effective for kidney transplantation recipients with tertiary hyperparathyroidism when they require cinacalcet-based medical management for more than 9 months. As part of shared decision-making, it is important to discuss the financial costs involved in treating tertiary hyperparathyroidism.