Cseprekal Orsolya, Jacquelinet Christian, Massy Ziad
Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary.
Agence de la Biomedicine, La Plaine Saint-Denis, Île-de-France, Paris, France.
Clin Kidney J. 2024 Dec 9;17(12):sfae335. doi: 10.1093/ckj/sfae335. eCollection 2024 Dec.
Pre-emptive kidney transplantation (PKT) has long been considered the optimal treatment for patients with end-stage chronic kidney disease (CKD) seeking the most favourable long-term outcomes. However, the significant growth in transplant procedures over recent decades has led to a notable increase in wait-listed patients and a disproportionate demand for donor organs. This situation necessitates a re-evaluation of transplantation timing and the establishment of rational indications from both societal and clinical perspectives. An increasing number of retrospective analyses have challenged the universal benefit of PKT, suggesting that premature indications for living or deceased donor PKT may not always yield superior hard outcomes compared with non-PKT approaches. Conventional predictive models have shown limitations in accurately assessing risks for certain subpopulations, potentially leading to significant disparities among wait-listed patients. To address these challenges, we propose the following considerations. Prediction models should not only optimize the distribution of our limited donor resources, but should also illuminate foreseeable risks associated with a potentially 'unsuccessful' PKT. Therefore, this article seeks to underscore the necessity for further discourse on the smouldering concept of when and for whom living or deceased donor PKT should be considered. Is it universally beneficial, or should the clinical paradigm be re-evaluated? In the endeavour to attain superior post-PKT survival outcomes compared with non-PKT or conservative treatment, it seems critical to acknowledge that other treatments may provide more favourable results for certain individuals. This introduces the intricate task of effectively navigating the complexities associated with 'too early' or 'unsuccessful' PKT.
长期以来，预先肾移植（PKT）一直被认为是寻求最有利长期预后的终末期慢性肾病（CKD）患者的最佳治疗方法。然而，近几十年来移植手术的显著增长导致等待名单上的患者显著增加，以及对供体器官的需求不成比例。这种情况需要从社会和临床角度重新评估移植时机并确定合理的适应症。越来越多的回顾性分析对PKT的普遍益处提出了质疑，表明与非PKT方法相比，活体或尸体供体PKT的过早适应症并不总是能产生更好的硬性预后。传统的预测模型在准确评估某些亚组的风险方面存在局限性，这可能导致等待名单上的患者之间存在显著差异。为应对这些挑战，我们提出以下考虑因素。预测模型不仅应优化我们有限的供体资源分配，还应阐明与潜在“不成功”的PKT相关的可预见风险。因此，本文旨在强调有必要进一步讨论何时以及对谁应考虑进行活体或尸体供体PKT这一潜在概念。它是否普遍有益，还是应该重新评估临床范式？为了在PKT后获得比非PKT或保守治疗更好的生存结果，似乎至关重要的是要认识到其他治疗方法可能对某些个体提供更有利的结果。这就引入了有效应对与“过早”或“不成功”的PKT相关的复杂性这一复杂任务。
