Preemptive living donor kidney transplantation: Do the benefits extend to all recipients?

Background. Preemptive kidney transplantation (prior to the institution of dialysis) avoids the morbidity and mortality of dialysis; however, detailed studies of high-risk patients are lacking. The aim of the current study was to compare recent outcomes of preemptive (P) versus nonpreemptive (NP) living donor kidney transplantation with an emphasis on high-risk recipients. Methods. We retrospectively analyzed 438 sequential solitary living donor kidney transplants at our institution between January 2000 and December 2002. In all, 44% were preemptive. NP recipients were dialyzed for 21 +/- 36 months (range 1-312 months). Results. Overall, three-year patient survival was similar in the NP and P groups. When stratified by diabetes and age > 65 years, P and NP recipients again showed similar survival. Death-censored three-year graft survival was better in the P group (97% vs. 90%, P=0.01), but was not significant by multivariate analysis. Delayed graft function was more frequent in NP vs. P (10% vs. 4%; P=0.01), but other early complications were similar including: acute rejection, 16% vs. 11% (P= 0. 11); primary nonfunction, 3% vs. 2% (P= 0.38); and wound complications, 19% vs. 17% (P= 0.54). Glomerular filtration rate at three years was similar in the two groups (53 +/- 23 preemptive vs. 52 +/- 20 ml/min nonpreemptive; P=0.37). Conclusion. With prompt referral and workup, preemptive kidney transplantation can be performed successfully in a large percentage of renal allograft recipients. Preemptive transplantation avoids unnecessary dialysis and should be emphasized as initial therapy for many patients with end-stage renal disease.