Preemptive Kidney Transplantation Not Associated With Better Survival in US Registry Study

Kidney transplantation before dialysis is considered optimal therapy for kidney failure, but its presumed survival advantage may reflect selection, confounding, and lead-time biases. This retrospective study in JAMA Network Open used US Scientific Registry of Transplant Recipients data from 2005–2023 to emulate a target trial. It included 32,770 adult first kidney-alone transplant recipients whose recorded wait-time start occurred at an estimated glomerular filtration rate of 20 mL/min/1.73 m² or less. Investigators used inverse probability weighting and left-truncated survival models to address these biases.

Among 15,894 preemptive and 16,876 nonpreemptive recipients, 6,827 deaths occurred over more than 265,369 person-years. Preemptive transplantation was not associated with lower mortality (hazard ratio [HR], 1.02; 95% CI, 0.96–1.07). It was associated with lower odds of delayed graft function (odds ratio, 0.68; 95% CI, 0.64–0.72) and lower death-censored graft failure (HR, 0.81; 95% CI, 0.74–0.88). The latter association was largely attenuated after adjustment for delayed graft function. All-cause graft failure was not significantly associated with transplant timing (HR, 0.96; 95% CI, 0.91–1.00).

These findings question an assumed mortality advantage while supporting potential early graft-function benefits. However, this was an observational analysis restricted to transplant recipients, not a randomized comparison of treatment strategies for all patients with kidney failure. Residual confounding remains possible; only the abstract was available for this update.