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[Kidney transplantation before starting dialysis therapy]
G P Segoloni1, G B Piccoli, G Leonardi
1Cattedra di Nefrologia dell'Universita' di Torino - Centro Trapianti Renali U.O.A.D.U. Nefrologia Dialisi e Trapianto - Azienda Ospedaliera S. Giovanni di Torino, Torino, Italy.
Summary
Pre-emptive kidney transplantation, performed before dialysis, shows improved graft survival and fewer rejections compared to post-dialysis transplants. This approach offers better patient rehabilitation and reduces job loss, challenging earlier concerns.
Area of Science:
- Nephrology and Transplant Surgery
- Immunology and Clinical Medicine
Background:
- Pre-emptive transplantation rates vary significantly worldwide, with some countries showing high adoption and others minimal or no use.
- Early concerns about pre-emptive transplantation centered on potential immunosuppression reduction due to lower uremia levels pre-dialysis.
- Historical clinical observations, particularly pre-cyclosporine era, fueled these initial apprehensions.
Purpose of the Study:
- To evaluate the outcomes and benefits of pre-emptive kidney transplantation.
- To compare graft and patient survival rates between pre-emptive and non-pre-emptive transplantation.
- To assess the impact of pre-emptive transplantation on patient rehabilitation and quality of life.
Main Methods:
- Analysis of clinical adoption rates of pre-emptive transplantation across different countries.
- Review of studies demonstrating graft and recipient survival.
- Examination of a large retrospective study (over 8000 living donor grafts) comparing pre-emptive and dialysis-treated cohorts.
Main Results:
- Pre-emptive transplantation is associated with significantly better recipient and graft survival.
- A large study showed a 52% reduction in graft losses post-first year and lower acute rejection rates in pre-emptive recipients.
- Pre-emptive recipients experience better rehabilitation and a reduced risk of job loss; concerns about patient compliance are largely unfounded with proper preparation.
Conclusions:
- Pre-emptive kidney transplantation offers superior long-term outcomes compared to transplantation after dialysis initiation.
- The benefits include enhanced graft survival, reduced rejection, improved patient recovery, and better quality of life.
- Living donor kidneys are preferred for pre-emptive transplantation due to cadaver donor shortages, though cadaver donors may be used in specific patient groups or programs.