[Transplantation before dialysis: a statement in favor].
Preemptive kidney transplantation is currently considered the optimal initial form of renal replacement therapy not only in terms of clinical outcome (recipient and graft survival) but also in terms of quality of life and social rehabilitation. The benefit of preemptive transplantation is clearly documented by an increasing number of studies based on many single-center experiences and also on the data of international registries. The advantages of receiving a transplant before dialysis (or at least within a few months of its initiation) are statistically evident both in patients receiving cadaver donor grafts and in those receiving living donor grafts. Among the factors that are considered responsible for these favorable results, the avoidance of dialysis-associated morbidity, the lower risk of acute and chronic rejection, the reduced frequency of delayed graft function, and the reduced frequency of cardiovascular mortality seem to play an important role. In the development of a preemptive transplantation program, however, some ethical issues must be carefully considered. At the moment, at least in most Italian regions, there is a persistent discrepancy between the number of kidney patients transplanted yearly and those still on the waiting list. How and when to allocate kidneys harvested from deceased donors to recipients not yet on dialysis remains a matter of debate. Preemptive allocation limited to elderly candidates who accept a double kidney transplant from marginal deceased donors is the most feasible choice at the moment. If a living donor is available, however, preemptive transplantation is mandatory and its implementation mainly depends on the efficacy of nephrologic counseling before the initiation of dialysis.
Segoloni
Giuseppe P
GP
SCU Nefrologia Dialisi e Trapianto, A.O.U. Molinette S. Giovanni, Torino, Italy. giuseppe.segoloni@unito.it
D006801:Humans; D016030:Kidney Transplantation; D011322:Primary Prevention; D006435:Renal Dialysis