Preemptive Kidney Transplantation

Abstract

End-stage renal disease (ESRD) is a severe health problem with high mortality and morbidity rates and growing incidence worldwide. Recently, two main renal replacement therapy modalities have been used for ESRD patients: Dialysis and kidney transplantation. It is undoubtedly clear that transplantation is the best choise for long term survival and every transplantation candidate is also a preemptive transplantation candidate. Preemptive kidney transplantation(PKT) may be summarized as transplantation before the commencement of dialysis in ESRD patients. Preemptive transplantation confers a significant benefit in terms of both patient and allograft survival. The benefit thought to be the result of avoidence of cardiovascular adverse effects of long term dialysis. Current opinion allows ESRD patients to receive PKT when their GFR is 20 mL per minute or less and preparation for transplantation should be started at the time of the diagnosing chronic renal disease. Kidney transplantation should be the choise of therapy in ESRD patients not only because of improving graft and patient survival and also preventing dialysis related comorbidities and lower cost in the long term(1,2,3). New and more effective immunsupressive drugs, growing experience in transplantation surgery are making kidney transplantation a more common and safe option. Although there are studies showing nephrologists have the same opinion that preemptive transplantation is the best treatment modality for eligible ESRD patients, that has been convincingly shown to improve posttransplant graft and patient survival. Unfortunately, while PKT is much more beneficial over transplantation, preemptive kidney transplantation seems to be underutilized specially as a result of late referral of the patients to a nephrologist and transplantation center. Only 2% of ESRD patients receive PKT while one forth of transplantation procedures are preemptive in children in the USA. Of course, there are other difficulties for PKT such as poor health status, lack of compliance, comorbidities, older patients, longer waiting time for deceased kidney donors and lack of social insurance. Ideally, preparation for transplantation should be initiated as soon as progressive chronic kidney disease (CKD) is recognized because cardiovascular morbidity and mortality rates increases while CKD progresses. Early referral to a nephrologist has a vital importance in this situation. Unfortunately, just about 50% of CKD patients come upon a nephrologist in end stage of chronic renal disease. Early referral not only allows careful preparation for PKT and also evaluation of potential living donor candidates and selecting the exact time for transplantation. Because the course of CKD varies according to the primary disease, earliest referral is synonymous to early preparation and beter outcome for transplantation.