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Preemptive Kidney Transplant (PKT) – the Optimal Therapy in ESRD

Preemptive Kidney Transplant (PKT) – the Optimal Therapy in ESRD. Reference: Connie L. Davis. Preemptive transplantation and the transplant first initiative. Curr Opin Nephrol Hypertens . 19:592–597.

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Preemptive Kidney Transplant (PKT) – the Optimal Therapy in ESRD

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  1. Preemptive Kidney Transplant (PKT) – the Optimal Therapy in ESRD Reference: Connie L. Davis. Preemptive transplantation and the transplant first initiative. CurrOpin Nephrol Hypertens. 19:592–597.

  2. Preemptive kidney transplant (PKT) in end-stage renal disease (ESRD) is considered as the mainstay of treatment considering the potential benefits it renders. • However, despite its reported benefits in chronic kidney disease (CKD), PKT therapy has not gained enough limelight so far due to certain barriers. In fact, initiatives are being undertaken to increase cases of transplantation first, otherwise called preemptive transplantation, prior to the need for initiating dialysis. • In order to make these initiatives effective, it becomes imperative to analyze the outcomes of preemptive transplantation from current findings, the impediments to it as well as the impact of living kidney donation.

  3. In about 16.6–21.3% of listed patients preemptive listing for kidney transplantation has been observed. • Among several factors, education level has potential influence on preemptive listing with the poor listing being observed if they patients have a high school education, compared to those with post-college graduate school. • It has been observed that recipients of preemptive transplants frequently include younger, white, working, nondiabetic, with private health insurance coverage. • In addition, access to care also influences the PKT access. In patients who has a poor health status, nonadherent, has various medical complications, is ‘too old’, is not covered under prescription drug coverage or has insufficient health insurance that can not cover the transplantation costs, nephrologists often consider not to discuss PKT. • Figure 1 depicts the rate of kidney transplantation based on the dialysis status.

  4. Benefits of Preemptive Transplantation • The potential benefits of PKT include: • Decreased graft rejection rate, improved survival of the recipient and the graft as well. (see Fig.2). • Improved graft function and patient survival rate found in all age groups (Figure 3). • Improved quality of life and growth of the young. • Diabetic patients better in long-term survival with PKT. • Other benefits such as cost cuttings through avoidance of dialysis, decreased sensitization rates, fewer catheter-induced infections from dialysis, fewer events of hepatitis, less cardiac systolic disorders and hypertension, decreased rate of hospitalization etc.

  5. Limitations of Preemptive Transplantation • Some of the major limitations of PKT are: • Inability to consider such factors as patient characteristics, practice patterns etc. that may affect the outcome with PKT. • The presence of comorbidities in the recipient with CKD, which is likely to impact the treatment outcome. • Bias such as selection of healthier patients.

  6. Impediments to Preemptive Transplantation • Different barriers indeed contribute to the significantly less number for PKT option. • Lack of transplant-related education • Delayed referral or in access to nephrology care and PKT • Lack of health insurance and reluctance of living kidney donation • Patient characteristics such as presence of comorbidities, too old age, non-compliance to treatment etc.

  7. Means to Improve Preemptive Transplantation Rate • Various means have to be employed to bring PKT to a better focus of the public. • The most important of these is to initiate awareness among the patient population as well as the entire community regarding kidney disease through educational programmes. • Patient education should focus on the benefits of PKD and the means to obtain it. • Dialysis and transplantation centres should collaborate in propagating such message. • Also health insurance policies should furnish medical coverage for immunosuppression of graft kidneys and for the living donor himself. • This would encourage individuals to step forward to donate their kidney.

  8. Conclusion • Based on the positive findings, it can be rightly stated that preemptive transplantation is the optimal therapy in patients with ESRD. • Provided the above means to attain the goal of increased PKT are employed effectively, morbidity and mortality associated with chronic kidney disease can be, in fact, diminished. • Improved living donor protections and immunosuppression coverage for allograft survival are essential. • Community education pertaining to living donor transplantation and policy related to living donor health coverage are essential to be addressed.

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