Preemptive kidney transplantation (PKT) has long been considered the optimal treatment
for patients with end-stage chronic kidney disease (CKD) seeking the most favorable
long-term outcomes. However, the significant growth in transplant procedures over
recent decades has led to a notable increase in waitlisted patients and a disproportionate
demand for donor organs. This situation necessitates a reevaluation 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 to non-PKT approaches. Conventional
predictive models have shown limitations in accurately assessing risks for certain
subpopulations, potentially leading to significant disparities among waitlisted patients.
To address these challenges, we propose the following considerations. Prediction models
should not only optimize the distribution of our limited donor resources but also
illuminate foreseeable risks associated with a potentially ‘unsuccessful’ PKT. Therefore,
our paper seeks to underscore the necessity for further discourse on the smoldering
concept of when and for whom living or deceased donor PKT should be considered. Is
it universally beneficial, or should the clinical paradigm be reevaluated? In the
endeavor to attain superior post-PKT survival outcomes compared to non-PKT or conservative
treatment, it seems critical to acknowledge that other treatments may provide more
favorable results for certain individuals. This introduces the intricate task of effectively
navigating the complexities associated with ‘too early’ or ‘unsuccessful’ PKT.
