Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model.
Jones-Hughes T, Snowsill T, et al.Health Technology Assessment (Winchester, England) 2016; 20(62): 1-594.
Aims
This systematic review aimed to update and review evidence for the clinical effectiveness and cost-effectiveness of induction and maintenance immunosuppressive therapies in renal transplant patients.
Interventions
Extensive literature searches were performed in MEDLINE, EMBASE, Cochrane databases, Web of Science, NHS EED, EconLit, and HEED with separate searches for systematic reviews. In addition hand searching was also conducted in trial registries and renal association websites. Studies evaluating the following induction and maintenance therapies were included; basiliximab (BAS)and rabbit anti-human thymocyte immunoglobulin (rATG), tacrolimus (TAC), prolonged release (TAC-PR), mycophenolate mofetil (MMF), mycophenolate sodium (MPS), belatacept (BEL), sirolimus (SRL) and everolimus (EVL) .
Participants
This review included adult kidney transplant reciepients receiving immunosuppressive therapy.
Outcomes
The main outcomes of interest were categorised as mortality, graft-related outcomes, adverse events data and health related quality of life.
Follow-up
For induction therapy studies follow up was between 6 months - 7 years, with most around 1 years an
CET Conclusions
This systematic review and economic analysis from the HTA looks at the relative clinical and cost-effectiveness of induction and maintenance immunosuppressive strategies in renal transplantation. It is a very ambitious document, and is important as the findings form the basis for the updated immunosuppressive guidelines from NICE in the UK, which have proven very controversial. The authors conclude that there is very little long-term data and a lot of heterogeneity in existing studies. They find little evidence to recommend one maintenance agent over another in terms of clinical effectiveness, and conclude that a combination of basiliximab, tacrolimus and MMF are likely to be the most cost-effective based upon the current costs and results of the network meta-analyses performed. Some limitations should be noted. The scope of the review only covers initial immunosuppression in patients able to tolerate these agents, and does not consider conversion to mTOR inhibtors etc. at a later date. The follow-up in most included studies is short. A number of notable large studies are excluded due to the use of other induction agents (e.g. Symphony (daclizumab) and 3C (alemtuzumab)). No consideration is given to steroid maintenance/withdrawal. Many of the network meta-analyses have a large amount of heterogeneity with little direct evidence for treatment comparisons, meaning that the subsequent use in an economic model may not be wise.
Quality notes
Quality assessment not appropriate
Trial registration
Prospero - CRD42014013189