Available via license: CC BY-NC 3.0
Content may be subject to copyright.
Original Article
http://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)
Iran University of Medical Sciences
____________________________________________________________________________________________________________________
1. MSc of Health Economics, Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sci-
ences, Kerman, Iran. s.yaghubi91@yahoo.com
2. Assistant Professor, Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical
Sciences, Kerman, Iran. rgoudarzi@kmu.ac.ir
3. Assistant Professor, Regional Centre for Training of HIV / AIDS, Institute for Futures Studies in Health, Kerman, Iran.
abbas_etminan@yahoo.com
4. Associate Professor, Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical
Sciences, Kerman, Iran. rbaneshi@yahoo.com
5. (Corresponding author) Assistant Professor, Modeling in Health Research Center , Institute for Futures Studies in Health, Kerman Universi-
ty of Medical Sciences, Kerman, Iran. mohsenbarooni @gmail.com
6. Health Insurance Organization, Head of Kerman office, Kerman, Iran. yamahdi1386@yahoo.com
Cost-effectiveness analysis of dialysis and kidney transplant in
patients with renal impairment using disability adjusted life years
in Iran
Safiye YaghoubiFard1, Reza Goudarzi2, Abbas Etminan3, MohammadReza Baneshi4
Mohsen Barouni*5, Mohammad Jafari Sirizi6
Received: 12 August 2015 Accepted: 18 February 2016 Published: 28 June 2016
Abstract
Background: This cross-sectional study was conducted to compare the cost-effectiveness of three therapeutic
methods of long-term hemodialysis, kidney transplant from a living person and kidney transplant from a cadaver
utilizing Disability Adjusted Life Years (DALY) using data from the records of patients referred to Afzalipour
Hospital of Kerman in 2012.
Methods: This cross-sectional study utilizing Disability Adjusted Life Years (DALY) as outcome measure,
used data from the records of patients referred to Afzalipour Hospital of Kerman in 2012. The decision tree
model and decision tree software (Tree Age pro 11) were used for data analysis. In this research, costs and ef-
fects were studied from the patients and healthcare providers’ perspective.
Results: In the patient’s perspective, the CER of dialysis was 5.04 times greater than transplant from a living
person and 6.15 times higher than transplant from a cadaveric donor. In the hospital’s perspective, the average
cost-effectiveness ratio of dialysis was 8.4 times greater than transplant from a living person and 14.07 times
higher than transplant from a cadaver. The smaller the C-E ratio, the greater was the cost-effectiveness. In both
perspectives, the order of effectiveness of treatment methods were transplant from a cadaver, transplant from a
living person and dialysis.
Conclusion: Considering the results obtained in this study, measures should be taken to increase the desire for
organ donation from brain-dead patients, living people and patients’ relatives.
Keywords: Cost-Effectiveness, DALY, Chronic Dialysis, Kidney Transplant.
Cite this article as:YaghoubiFard S, Goudarzi R, Etminan A, Baneshi MR, Barouni M, Jafari Sirizi M. Cost-effectiveness analysis of
dialysis and kidney transplant in patients with renal impairment using disability adjusted life years in Iran. Med J Islam Repub Iran 2016 (28
June). Vol. 30:390.
Introduction
With the changing face of health in the
last two decades in Iran, changes can be
observed in the disease patterns with the
increasing trend of chronic diseases such as
renal diseases (1). End-stage renal disease
(ESRD) is an incurable condition with irre-
versible loss of kidney function (2). Renal
failure is a major public health problem in
the world, which is referred to temporary or
permanent kidney damage, leading to loss
of normal kidney function. According to
the report of the Transplant and Specific
Diseases Management Center of the Minis-
try of Health, 320,000 people in the country
suffer from renal failure; of whom, 49%
use the transplantation treatment method,
48% hemodialysis and 3% use peritoneal
Cost-effectiveness analysis of dialysis and kidney transplant
2
Med J Islam Repub Iran 2016 (28 June). Vol. 30:390.
http://mjiri.iums.ac.ir
dialysis method. The growing trend of this
disease in the world suggests that the num-
ber of patients receiving alternative treat-
ments such as renal transplantation, perito-
neal dialysis and hemodialysis is growing
as well (3).
Approximately 10 to 15 percent of the US
adult population is suffering from chronic
renal failure. The prevalence has been re-
ported 11.2% in Australia, 10.1% in Singa-
pore as a country in Southeast Asia and
18.7% in Japan (4). People with chronic
renal failure initially receive protective
treatment, but eventually require hemodial-
ysis. More than one million people are sur-
viving through dialysis worldwide (5). Re-
nal transplantation, which is being done in
our country for many years, is the treatment
of choice for chronic renal failure (6). In
the case of not receiving a successful kid-
ney transplant, these patients escape from
early death using new methods of treatment
such as dialysis. However, they are in a
wide range of physical, psychological, so-
cial and economic problems, which in gen-
eral, affect their quality of life (7).
A considerable proportion of the health
budget is allocated to the growing number
of patients with end-stage renal diseases
(ESRD). Therefore, the massive demand
for renal replacement therapy costs has be-
come a great burden for healthcare systems
in developing countries. Since chronic kid-
ney disease (CKD) and ESRD emerged as
public health problems in developing coun-
tries, a change in healthcare policies was
required (8).
Jensen et al. in 2014 (9), Elsharif et al. in
2010 (8), Howard et al. in Australia in 2009
(10), Perović and Janković in Serbia in
2009 (11) and Karimi et al. in 2005 per-
formed researches in this field (12).
This cross-sectional study aimed to de-
termine the cost-effectiveness of chronic
dialysis, kidney transplantation from a ca-
daver and kidney transplantation from a
living person in Afzalipour Hospital of
Kerman province in Iran using DALY
measure.
Methods
This cross-sectional study was conducted
to compare the cost and effectiveness of
three therapeutic methods of long-term he-
modialysis, kidney transplant from a ca-
daver and kidney transplant from a living
person utilizing DALY measure, using data
from the records of patients referred to
Afzalipour Hospital of Kerman for treat-
ment in 2012. The statistical population of
the study was all the records of patients
hospitalized in Afzalipour hospital for kid-
ney transplantation in 2012, and patients
who referred to this hospital for chronic
dialysis since the beginning of 2012. In this
study, the records of 32 chronic dialysis
patients and 97 kidney recipients aged 12-
84 years who underwent dialysis or kidney
transplant for the first time were studied.
One person was in both the transplant and
dialysis groups and therefore removed due
to the overlap. Dialysis group included 9
females and 23 males, and the transplant
group included 30 females and 67 males.
The transplant from a cadaver group in-
cluded 29 patients, and the transplant from
a living person group included 68 patients.
This study examined this topic from two
perspectives: The costs and outcomes from
the patients, and the service provider organ-
ization (Afzalipour Hospital). The data-
gathering tool was a two-part predeter-
mined form designed by the researcher.
The first part of the predetermined forms
included demographic characteristics, type
of treatment and duration of hospitalization,
fees and contact information of the patients.
The second part contained such information
as the starting date of dialysis or transplan-
tation, date of death or transplant rejection,
costs of monthly tests and checkups, travel
costs for the patients and the person ac-
companying them, and accommodation
costs for the person accompanying the pa-
tients, which were collected through phone
or live interviews with the patients or their
families (Fig. 1). Data were analyzed using
the decision tree model and Tree Age
Software.
S. YaghoubiFard, et al.
3
Med J Islam Repub Iran 2016 (28 June). Vol. 30:390.
http://mjiri.iums.ac.ir
Costs
In this study, direct medical costs
(equipments used and personnel fees) and
tariffs paid by the patients or the supporting
centers for dialysis and kidney transplanta-
tion patients were calculated. Indirect costs
including travel costs, accommodation
costs and expenses resulting from the ab-
sence from work were also included. The
cost of work absenteeism is equal to the
daily income multiplied by the number of
times of treatments.
Effectiveness
Effectiveness of the interventions was
calculated based on DALY measure.
DALY is a combination of two elements:
Years lived with disability (YLD) and years
of life lost (YLL).
Equation 1: Disability- Adjusted Life
Year (DALY)
DALY= YLL+ YLD
Equation 2: Years of life lost (YLL).
YLLS=
+
Equation 3: Years lived with disability
(YLD)
YLDS=D
“K” is the relative value of age (1), “β” is
the World Bank's parameter (0.04), “C” is
comparative constant (0.16243), “e” is the
base of the natural logarithm, “D” is disa-
bility weight and discount rate or “r” is
0.03. “L” is the average treatment duration
(in years) in YLD and raw years lost in
YLL and “a” is the age having the disabil-
ity in age group in YLD and age at the time
of death in YLL (13) .The disability weight
was considered 0.155 for dialysis and 0.05
for transplantation (14). To calculate the
cost and effectiveness, patients treated with
the two methods of transplantation from a
living person and transplantation from a
cadaver were categorized into three groups
of died, successful transplantation and un-
successful transplantation; and using dialy-
sis treatment method, they were classified
into two groups of died and alive.
Fig. 1. Decision Tree Model for Three Methods of Transplant from a
Cadaver, Transplant from a Living Person and Dialysis
Cost-effectiveness analysis of dialysis and kidney transplant
4
Med J Islam Repub Iran 2016 (28 June). Vol. 30:390.
http://mjiri.iums.ac.ir
The long-term costs and consequences
were considered from the onset of the dis-
ease until the patient's death.
Modeling
The cost and effectiveness per patient was
entered into the Tree Age Software to plot
the model considering a discount rate of
0.03 (15) as well as the possibilities. Cost-
effectiveness ratio (CER) was calculated
using the following equation (Equation 1,
2). In this equation, cost is the average cost
per person in terms of million Rials and
effectiveness is the average effectiveness
per person based on DALY. Exchange rates
of 2012 were used to convert currencies.
Equation 4: Average Cost Effectiveness
Ratio
Equation 5: Incremental Cost Effective-
ness Ratio
Sensitivity Analysis
The decision tree and tornado diagram
were plotted. Considering the tornado dia-
gram, sensitivity analysis was performed
for the parameters that had the greatest im-
pact on the cost-effectiveness. One-way
and two-way sensitivity analysis was per-
formed. Performing a sensitivity analysis
requires high and low ranges for parameters
where these ranges were obtained with a
10% change in the parameters (16). Since
some parameters were not in the decision
tree model (relative value of age, disability
weight and discount rate) and were pre-
calculated, their sensitivity analysis was
performed using excel software. Sensitivity
analysis for effectiveness, cost and possibil-
ities was performed using Tree Age Soft-
ware.
Results
Result by Perspective
The results of the patient's perspective are
displayed in Table 1 and the perspective of
the health system in Table 2.
A) The patient’s perspective
The C-E ratio in transplant from a living
person was 3,181.07 dollar/DALY; it was
2,528.5 dollar/DALY in transplant from a
cadaver, and 15,986.9 dollar/DALY in
chronic dialysis. The cost-effectiveness ra-
tio of dialysis was 5.04 times greater than
Table 1. Direct and Indirect Cost in the Model
Type of
Treatment
Direct
Costs
(dollar)
Indirect
Costs
(dollar)
Total Costs
(dollar)
Weighted
Average Costs
with a Discount
Rate of 0.03
(dollar)
Effectiveness
(DALY)
Cost-Effectiveness
Ratio
(dollar/DALY)
Incremental
cost-
effectiveness
ratio (dollar
/DALY)
Kidney Trans-
plant from a
Cadaveric
60848.3
85236.5
146084.8
13295.3
5.12
2528.5
0
Kidney Trans-
plant from a
Living Person
107096.2
77487.7
184584.01
19657.4
6.18
3181.07
5954.3
Chronic dialysis
1174306.7
39151.7
1213539.9
104649.3
6.52
15986.9
256525.3
Table 2. The Cost-effectiveness Ratio of the Three Studied Interventions: Kidney Transplant from a Cadaveric, Kidney Transplant
from a Living Person, Chronic Dialysis (Costs in Dollar)
Type of Treatment
Direct Costs
(dollar)
Weighted Average Costs with
a Discount Rate of 0.03
(dollar)
Effectiveness
(DALY)
Cost-
Effectiveness
Ratio
(dollar/DALY)
Incremental cost-
effectiveness ratio
(dollar/DALY)
Kidney Transplant from a
Cadaveric
60848.3
5628.05
5.12
1060.4
0
Kidney Transplant from a
Living Person
107096.2
11419.2
6.18
1794.5
5383.4
Chronic dialysis
1174306.7
101305.05
6.52
15497.6
271288.7
S. YaghoubiFard, et al.
5
Med J Islam Repub Iran 2016 (28 June). Vol. 30:390.
http://mjiri.iums.ac.ir
transplant from a living person and 6.15
times larger than transplant from a cadaver.
The smaller the C-E ratio, the greater was
the cost-effectiveness; transplant from a
cadaver was more cost-effective than a
transplant from a living person and dialysis.
Transplant from a cadaver saved more than
5,954.3 dollar/DALY compared to trans-
plant from a living person and more than
65,171.3 dollar/DALY compared to dialy-
sis.
B) The Perspective of the Health System
The C-E ratio in transplant from a living
person was 1,794.5 dollar/DALY, it was
1,060.4 dollar/DALY in a transplant from a
cadaver and 15,497.6 dollar/DALY in
chronic dialysis. The cost-effectiveness ra-
tio of dialysis was 8.4 times greater than
transplant from a living person and 14.07
times higher than transplant from a cadav-
er. The smaller the C-E ratio, the greater
was the cost-effectiveness; transplant from
a cadaver was more cost-effective than a
transplant from a living person and dialysis.
Transplant from a cadaver saves more than
5,383.4 dollar/DALY compared to trans-
plant from a living person and more than
68,352.4 dollar/DALY compared to dialy-
sis.
Considering Table 1, Table 2, and Graph
1, it can be concluded that in both the pa-
tients and the healthcare providers’ per-
spective, kidney transplantation from a ca-
daver treatment method was more cost-
effective than the other two methods of
transplantation from a living person and
dialysis. Compared to the cost-effective-
ness based on DALY measure, kidney
transplant method (transplant from living
person and cadaver) was far better than
chronic dialysis. The superiority of kidney
transplant method was 5 to 14 times the
chronic dialysis. Considering the tornado
diagram, one-way and two-way sensitivity
analysis was performed for the parameters
that had the greatest impact on the cost-
effectiveness. Two-way sensitivity analysis
was performed for the desired parameters
in pairs with respect to tornado diagram.
From the patient’s perspective, these pa-
rameters were dialysis costs for a living
person, the costs of a successful transplant
from a living person, the effectiveness of a
successful transplant from a living person,
the mortal effectiveness of a transplant
from a living person and the effectiveness
of a successful transplant from a living per-
son. The parameters for the hospital’s per-
spective included the effectiveness of a
successful transplant from a cadaver, the
mortal effectiveness of a transplant from a
cadaver, the probability of unsuccessful
transplant from a cadaver, the costs of a
successful transplant from a cadaver and
the effectiveness of unsuccessful transplant
from a cadaver. The results were not sensi-
tive to the desired parameters, meaning that
transplant from a cadaver is still superior to
transplant from a living person and dialysis.
In general, kidney transplant is superior to
dialysis method as it causes less inability in
patients.
Discussion
This study focused on the cost-
effectiveness of dialysis, kidney transplant
from a cadaver and transplant from a living
person, using DALY measure. The reason
for using cost-effectiveness analysis was
that although dialysis and kidney transplant
both increase the longevity, the obvious
difference between the quality of life re-
quired comparing the benefits of the three
treatment methods. The model used in this
analysis calculated the cost-effectiveness of
hemodialysis, transplant from a cadaver
and transplant from a living person. The
three outcomes of death, successful trans-
plant and transplant rejection were consid-
ered. The results of this study revealed that
kidney transplant from a cadaver is more
cost-effective than the other two treatment
methods of transplant from a living person
and dialysis. Sensitivity analysis showed
that changes in probability, costs and effec-
tiveness did not affect the obtained results.
Therefore, we suggest that kidney trans-
plant from a cadaver is significantly better
than transplant from a living person, and
transplant from a living person is far better
Cost-effectiveness analysis of dialysis and kidney transplant
6
Med J Islam Repub Iran 2016 (28 June). Vol. 30:390.
http://mjiri.iums.ac.ir
than dialysis. According to Iran Central
Bank, the reference exchange rate was
12,260 Rials in 2012 (17). The main reason
for the difference between the results of
this study and those of others is based on
the issue of cost. In other words, the cost of
medical procedures was not based on cost
price.
The results of the study by Perović and
Janković revealed the followings: The cost
of dialysis: 22 8,161.61 dollar, the final
costs of dialysis: 228,161.61 dollar; the ef-
fectiveness of dialysis: 4.83 quality-
adjusted life years (CALY); and the final
effectiveness of dialysis: 4.83 CALY. The
cost of transplant was 67,536.7 dollar, the
final costs of transplant 160,603.6 dollar;
the effectiveness of transplant was 5.71
CALY and the final effectiveness of trans-
plant was 0.88 CALY. The cost-
effectiveness ratio of dialysis was estimated
to be 47,226.7 dollar/DALY and the cost-
effectiveness ratio of transplant was
182,463.3 dollar/DALY (11).
The results of the study by Elsharifet al.
revealed that the annual costs of hemodial-
ysis was 6847/00 dollar, the total costs of
the first year after kidney transplant was
14,825/04 dollar and the costs of kidney
transplant after the first year was 10,651
dollar. Total days of hospitalization and
absence from work were lower in the trans-
plant group. In Sudan, kidney transplant
was less expensive than hemodialysis (8).
In Jensen’s study in Denmark in 2014, the
costs of dialysis was 189,529.17 dollar, the
costs of transplant 148,718.53 dollar, the
effectiveness of dialysis 1.7 and the effec-
tiveness of transplant was 4.4. ICER was
estimated 14,518.8 dollar/DALY which led
to the saving 40,783.03 dollar/2.8 CALY
compared to dialysis (9).
In the study conducted by Karimiet al. in
Iran, the average costs of treatment period
in the chronic dialysis method was 13,213.7
dollar for female patients and 10,114.1 dol-
lar for male patients, and it was estimated
2,446.9 dollar for female patients and
2,283.8 dollar for male patients in the kid-
ney transplant method. The costs of treat-
ment period for chronic dialysis were de-
termined 859.3 dollar and 195.8 dollar for
kidney transplant method. The cost-
effectiveness difference between the two
methods was higher in male patients
(1,876.01 dollar per one DALY) compared
to female patients (1,468.2 dollar per one
DALY) (12).
The results obtained in this study con-
firmed the results of the above-mentioned
studies that indicated kidney transplant is
more cost-effective than dialysis. However,
in contrast to the results obtained in this
study, in the study by Kaminota, transplant
from a living person is more cost-effective
than transplant from a cadaver. In this
study, the treatment methods in order of
cost-effectiveness are transplant from a ca-
daver, transplant from a living person and
dialysis.
This study has some limitations: Only pa-
tients’ statements were considered in calcu-
lating the indirect costs such as the costs of
traveling; there was no congruence between
patients due to the lack of a sufficient num-
ber of patients in this area; moreover, we
used the discount rate of 0.03 from other
studies because discount rate has not been
calculated in Iran.
Given the results of this study, the culture
of organ donation from brain dead patients
should be promoted because only 30% of
the families of brain dead patients consent
to organ donation three out of every 10
people). In general, considering the find-
ings of this study, measures should be taken
to increase the tendency for organ donation
from brain dead and living individuals and
family members of the patients. Transplan-
tation from a living donor could be consid-
ered due to the long waiting time of pa-
tients and lack of donated organs. This
study suggests kidney transplant more than
dialysis as it results in better quality of life
and higher life expectancy.
Conclusion
The results of this study with respect to
both the patients and the healthcare provid-
ers’ perspectives suggest that transplant
S. YaghoubiFard, et al.
7
Med J Islam Repub Iran 2016 (28 June). Vol. 30:390.
http://mjiri.iums.ac.ir
from a cadaver is more cost-effective than
the other two treatment methods of trans-
plant from a living person and dialysis. We
suggest that measures be implemented to
increase the desire for organ donation from
brain dead patients, living people and pa-
tients’ relatives. Moreover, the government
should allocate more resources to kidney
transplant programs.
Acknowledgments
This study was a part of a master's thesis
on Health Economics at Kerman University
of Medical Sciences. We are grateful to all
the officials in Kerman University who
supported this study. In addition, we appre-
ciate the kind assistance of Dr. Amir Vian-
chi.
References
1. Amini Z, Fazel Asghar Poor A, Zeraati A,
Esmaeeli H. The effect of Roy’s adaptation model-
based healthcare program on daily living activities
of hemodialysis patients. Journal of North Khorasan
University of Medical Sciences 2012;4(2):145-53.
2. Abbas Zadeh A, Javanbakhtian R, Salehi Sh,
Motevasselian M. A comparative study of quality of
life in hemodialysis patients and renal transplant
recipients. Scientific Journal of Shahid Sadoughi
University of Medical Sciences in Yazd 2010;
18(5):461-8.
3. Amirkhani M, Nouhi E, Jamshidi H.
Comparative study of quality of life in patients
receiving kidney transplant with hemodialysis and
peritoneal dialysis patients in 2012 in Kerman.
Journal of Fasa University of Medical Sciences
2014;4(1):126-33.
4. Khalkhali H, Hajizadeh E, Kazem Nezhad A,
Ghaffari Moghaddam A. Prediction of renal failure
in patients with chronic impaired function of
transplanted kidney. Iranian Journal of
Epidemiology 2010;6(2):25-31.
5. Hashemi M,Garshad A. Dialysis adequacy and
some biochemical factors associated with it in
hemodialysis patients in Imam Ali Hospital of
Bojnord. North Khorasan University of Medical
Sciences 2012;4(4):665-70.
6. Azmandian J, Shafie Z, Sohrevardi S M, Fazeli
F, EtminanA, Azizi Shool S. The effect of addition
of low doses of Daclizumab to the standard protocol
in reducing transplant rejection in renal transplant
recipients. Knowledge & Health Quarterly 2011;
6(6):1-4.
7. Tayebi A, Salimi SH, Mahmoudi H, Tadrisi SD.
Comparison of quality of life in dialysis and kidney
transplantation patients. Journal of Critical Care
Nursing 2010;3(1):19-22.
8. Elsharif ME, Elsharif EG, Gadour WH. Costs of
hemodialysis and kidney transplantation in Sudan: a
single center experience. Iranian journal of kidney
diseases 2010;4(4):282-4.
9. Jensen CE, Sørensen P, Petersen KD. In
Denmark kidney transplantation is more cost-
effective than dialysis. Danish medical journal
2014;61(3):A4796-A.
10. Howard K, Salkeld G, White S, Mcdonald S,
Chadban S, Craig JC, et al. The cost‐effectiveness of
increasing kidney transplantation and home‐based
dialysis. Nephrology 2009;14(1):123-32.
11. Perović S, Janković S. Renal transplantation vs
hemodialysis: cost-effectiveness analysis.
Vojnosanitetski pregled 2009;66(8):639-44.
12. Karimi I, Zohoor A, Vianchy A. Comparative
study of cost-effectiveness of dialysis and kidney
transplant a from using Dali index, at Shahid
Hasheminejad Hospital. Quarterly Journal of
Medical Management and Information 2014;
7(16):46-9.
13. Hajizadeh M. Health economics. Tehran:
Jamee Negar Publications 2008:137- 44.
14. Nafar M, Mousavi SM, Mahdavi M, Pour-
Reza-Gholi F, Firoozan A, Einollahi B, et al.
Burden of Chronic Kidney Disease in Iran A
Screening Program is of Essential Need. Iranian
Journal of Kidney Diseases (IJKD) 2008;2(4):183-
92.
15. Sari AA, Ravaghi H, Mobinizadeh M, Sarvari
S. The Cost-Utility Analysis of PET-Scan in
Diagnosis and Treatment of Non-Small Cell Lung
Carcinoma in Iran. Iranian Journal of Radiology
2013;10(2):1-7.
16. Ahmad T, BadieiSh, Gupta A, Stokes J,
Vamos E. Cost utility analysis of transplantation
versus dialysis in elderly patients in the UK 2013.
17. Central Bank of the Islamic Republic of Iran
[homepage on the Internt]. Tehran: The Central
Bank of the Islamic Republic of Iran; c2000-2012
[cited 2012 Apr 28]. Statistics and Data: exchange
rate. Available from: http://www.cbi.ir/ExRates/
rates_fa.aspx.
