Dialysis or transplant: an integrated approach to end-stage kidney disease management

Technological and immunological developments within the last decade have evolved a variety of therapeutic modalities by which ESRD may be satisfactorily managed. With the exception of renal transplantation between identical twins, none of these modalities provide permanent and complete correction of the uremic state, however, and the challenge now facing those involved in the management of irreversible renal failure is to devise an individualized treatment program permitting optimal long-term physical and psychological well-being and the maintenance of a valuable and productive role in society. Such a goal is most effectively achieved by an integrated approach combining both dialysis and renal transplantation. In the program proposed and utilized at our institution, all therapeutic options are presented to the patient with incipient renal failure, and a rational long-term management strategy devised based on clinical status, psychological stability, convenience, and acceptability. Dialysis is normally employed as a limited term maintenance procedure pending renal transplantation from a living or cadaver donor, thus permitting optimal correction of the uremic state. Early rehabilitation and social reintegration are actively pursued to minimize disease impact and maximize quality of life. In subjects with chronic deterioration of graft function, retransplantation may be performed prior to requirement for dialysis, thus minimizing hospitalization time, cost, and social disruption. The definition of risk factors predicting graft success has facilitated the individualization of therapy within this integrated program. While allograft survival exceeding 90% may now be anticipated in the non-sensitized first-graft recipient, predicted outcome is poor in subjects who are highly sensitized following previous transplantation or with rapid loss of a prior graft.(ABSTRACT TRUNCATED AT 250 WORDS)