Economic Evaluations of Kidney Paired Donation, ABO-Incompatible Kidney Transplantation, and Maintenance Dialysis in Different Resource Settings: A Systematic Review.

Compared with long-term dialysis, kidney transplantation offers substantially better patient survival; however, donor scarcity and immunological barriers such as blood-group and human leukocyte antigen (HLA) incompatibility keep many candidates from ever reaching transplant. Kidney paired donation (KPD) works around this barrier by matching incompatible pairs into exchange chains, whereas ABO-incompatible (ABOi) transplantation removes the barrier directly through desensitization protocols. Little is known about how these two strategies compare economically, or whether any advantage they hold up when resource availability differs, since almost all published cost data originates from high-income settings. Our objective was to locate, critically evaluate, and pool the available economic evidence on KPD, ABOi living-donor transplantation, and maintenance dialysis in adult end-stage kidney disease (ESKD) patients, examining in particular whether conclusions differ among high-, middle-, and low-resource countries. This review followed the PRISMA 2020 framework, incorporating its equity-focused reporting extension. Literature was retrieved from three databases (PubMed/MEDLINE, Embase, and the Cochrane Library) covering economic evaluations (both full and partial) published from 2016 through 2025. Screening, data extraction, and methodological quality assessment were each carried out independently by a pair of reviewers, with appraisal tools selected to match study design: the Consensus on Health Economic Criteria (CHEC) for cost studies, the Philips checklist for decision-analytic models, and the Newcastle-Ottawa Scale (NOS) for observational cohorts. Each included study was then classified by the World Bank income tier and by the specific type of economic analysis it employed. Ten eligible studies spanning six countries were identified: the United States, Netherlands, Sweden, Norway, United Arab Emirates, and Iran, with seven originating from high-income settings and the remaining three from Iran, the sole upper-middle-income country represented; no low- or lower-middle-income data were found. Across every study, the conclusion pointed the same way: transplantation proved more economical than dialysis. KPD carried a similar cost burden to other transplant modalities and produced savings of approximately US$100,000 per transplant relative to continued dialysis; in the Netherlands, a paired exchange program raised discounted quality-adjusted life years (QALYs) from 6.42 to 9.65, with a net gain of 4.05 QALYs once altruistic donor chains were factored in. ABOi transplantation, though costlier than ABO-compatible (ABOc) transplantation, remained cost-effective against dialysis at US$59,564 per QALY gained. Iranian data showed markedly favorable cost-effectiveness at US$1,744 per QALY. The lower absolute ratios seen in Iran are best attributed to reduced local healthcare costs rather than any fundamental difference in the underlying economic argument. Across all three comparisons, KPD, ABOi transplantation, and dialysis, transplantation consistently emerged as the more cost-effective route to renal replacement therapy (RRT). KPD stood out in particular, generating cost savings, health gains, and sparing patients the added expense of desensitization. The most notable limitation of the current evidence base is its near-total absence from lower-resource countries, precisely the settings where questions of affordability carry the greatest weight.