The kidney-first initiative: what is the current status of preemptive transplantation?

Preemptive kidney transplant (PKT)-defined as transplant before dialysis-has numerous advantages as a treatment approach for patients with advanced renal disease. In the past 15 years, PKT has become more common and has been performed at higher levels of estimated glomerular filtration rate, particularly among recipients of live-donor transplants, among whom timing of transplantation is easier to control. However, recent studies have raised important new concerns about unintended consequences of early versus late PKT. In this article, we review the convincing evidence that PKT offers diverse advantages for patients, discuss potential problems that might emerge from PKT at higher levels of renal function, examine the feasibility of a "just-in-time" PKT strategy for transplant centers, and discuss whether a new kidney allocation system could affect rates of PKT.