Consider Preemptive Kidney Transplantation, New Guidance Suggests

Despite limitations of the current evidence base, preemptive kidney transplant programs “should be stimulated”—offering the option to consider transplantation before dialysis becomes necessary—concludes a systematic review and position statement published in Nephrology Dialysis Transplantation.

A systematic literature review by the Descartes Working Group and the European Renal Best Practice Board identified 29 retrospective observational cohort studies providing information on preemptive living kidney donation. There were no randomized trials. Twenty-one papers reported on adult and 8 on pediatric recipients. Most studies used living-donor kidneys; only 2 studies reported using deceased-donor kidneys exclusively.

Patient survival was better with preemptive versus post-dialysis transplantation in 9 of 19 adult studies, with equivalent results in 4. Most studies reported better graft survival and acute rejection rates with preemptive transplantation. Outcomes were not significantly affected by dialysis periods of less than one year. Rates of delayed graft function with preemptive transplantation function ranged from 2.0 to 3.7%, compared to 4.0 to 9.7% with post-dialysis transplantation.

All papers were considered at high risk for selection bias; patients preemptively placed on the waiting list were in better health. There was no evidence of increased non-adherence among patients who had no previous experience with dialysis. Few studies assessed the effects of preemptive transplantation on long-term complications such as malignancy or infection.

Based on the findings, the authors call for increased awareness and early education about possible preemptive kidney transplantation. They add that decisions about preemptive transplantation should consider both clinical and biochemical findings, rather than any fixed level of glomerular filtration rate [Abramowicz D, et al. Does preemptive transplantation versus post–start-of-dialysis transplantation with a kidney from a living donor improve outcomes after transplantation? A systematic literature review and position statement by the Descartes Working Group and ERBP. Nephrol Dial Transplant 2016; 31:691–697].