An assessment of renal replacement therapy: A register-based study on equality of access, cost, effectiveness, and cost-effectiveness of kidney transplantation in Sweden

Renal replacement therapy, which includes dialysis and kidney transplantation, is a lifesaving treatment for patients with end-stage renal disease. Kidney transplantation is generally preferred over dialysis as it is associated with lower mortality, higher quality of life, and lower costs. Despite these advantages, the availability of kidney transplant to all who can benefit from it is limited by the scarcity of kidneys. The overall purpose of this thesis was to explore equality of access to kidney transplantation as well as the effectiveness, cost, and costeffectiveness of kidney transplantation relative to dialysis. The analyses were performed using data from the Swedish Renal Register, a Swedish national register for renal replacement therapy patients, which was linked to other national registers and regional healthcare utilization databases. Logistic regression models and Cox regression models were applied to study the association between income and education and access to kidney transplantation in general, access to the waitlist, and access to kidney transplantation conditional on waitlist placement. The double robust inverse-probabilityweighted regression adjustment approach was applied to estimate the potential outcome mean and the average treatment effect on survival time and healthcare costs. The results showed that patients with higher income and education had a higher chance of access to kidney transplantation in general than patients with lower income and education. After dividing the kidney transplantation process into access to the waitlist and access to kidney transplantation conditional on waitlist placement, the chance of waitlist access was larger than that of kidney transplantation access conditional on waitlist placement for both higher income and education patients. The survival advantage of kidney transplantation compared with dialysis was around 14 years. There was no significant difference in the survival advantage of kidney transplantation between men and women. Kidney transplantation was not cost-saving in the first year after kidney transplantation, but became cost-saving for the second year, the third year, over the three years, and over lifetime after kidney transplantation. In conclusion, the findings of this thesis show that there are inequalities related to socioeconomic status in the process of kidney transplantation. Moreover, the inequality in access to the waitlist is substantially larger than the inequality in access to kidney transplantation conditional on waitlist placement, and is therefore expected to contribute more to socioeconomic-status-related inequalities. Kidney transplantation increases survival time and reduces healthcare costs relative to dialysis treatment. This combination of inequality in access and advantage of transplantation over dialysis means that patients with advantageous socioeconomic status will have longer survival time and lower healthcare costs. However, there is no sex inequality in either access to kidney transplantation or survival advantage of kidney transplantation.