Pre-emptive transplants for patients with renal failure - An argument against waiting until dialysis

Background. Pre-emptive kidney transplants have not been favored in some ce nters because of concern about possible increased noncompliance and alleged ly inferior long-term results. We analyzed our experience with pre-emptive kidney transplants to determine whether such concerns are justified. Patients and Methods. Between January 1, 1984, and June 80, 1998, we perfor med 1849 adult primary kidney transplants: 385 pre-emptive (recipients not undergoing dialysis, ND) and 1464 non-pre-emptive (recipients undergoing di alysis, D), Results were subdivided by donor source: cadaver (CAD) and livi ng donor (LD). ND recipients tended to be younger, but otherwise, the two g roups were similar. Posttransplantation quality of life in recipients was e valuated using the nationally standardized Short Form Health Survey (SF-36) , The posttransplantation employment status of the recipients was also eval uated. Results. The patient survival rate 5 years posttransplantation was signific antly better for ND (vs, D) recipients for both CAD (92.6% vs. 76.6%, P=0.0 01) and LD (93.3% vs. 89.5%, P=0.02) transplants. The 5-year patient surviv al rate was significantly higher for ND recipients compared with recipients undergoing dialysis for < 1, 1-2, and > 2 years pretransplantation for bot h CAD (P=0.0005) and LD (P=0.0001) transplants. The graft, survival rate 5 years posttransplantation was similar between ND and D recipients for CAD t ransplants, but significantly better for ND (vs. D) recipients of LD transp lants (92.3% vs. 84.8%, P=0.006). For CAD transplants, the 5-year graft sur vival rate was not different when ND recipients were compared with recipien ts undergoing dialysis for < 1, 1-2, and > 2 years pretransplantation; for LD transplants it was significantly higher for ND recipients compared with recipients undergoing dialysis for < 1, 1-2, and > 2 years pretransplantati on (P=0.04). The incidence of acute and chronic rejection was no different between ND and D recipients for either CAD or LD transplants, and it was al so not affected by the pretransplantation time undergoing dialysis, Graft l oss secondary to the recipient's discontinuation of immunosuppressive thera py (a crude estimate of compliance) was similar between ND and D recipients . Five years posttransplantation, the SF-36 scores regarding the recipient' s quality of life and the employment status were similar for ND compared wi th D recipients, regardless of donor source. Conclusions. ND recipients do not seem to have higher rates of noncomplianc e than D recipients. Results for ND recipients seem to be superior than for I) recipients, supporting the contention that renal failure patients shoul d, if possible, undergo transplantation before dialysis.