Preemptive Kidney Transplant Tied to Less Delayed Graft Function, Not Lower Mortality

Kidney transplantation before dialysis initiation was not associated with improved patient survival compared with transplantation after dialysis began, according to a retrospective cohort study published in JAMA Network Open.

Preemptive kidney transplantation is promoted as optimal therapy for kidney failure, but evidence of a true survival advantage has been uncertain because of confounding, selection, and lead-time biases, the investigators noted. To address these biases, they used Scientific Registry of Transplant Recipients data to emulate a target trial.

The analysis included 32,770 adult first kidney-alone transplant recipients who were wait-listed before starting dialysis, 15,894 (48.5%) of whom received a preemptive transplant. The researchers balanced groups using inverse probability of treatment weighting and set a common starting point at the first recorded estimated glomerular filtration rate of 20 mL/min/1.73 m² or less to address lead-time bias. An apparent survival advantage for preemptive transplantation in crude analyses (hazard ratio [HR], 0.75; 95% CI, 0.71-0.79) was no longer present after bias adjustment (HR, 1.02; 95% CI, 0.96-1.07).

Preemptive transplantation was associated with lower odds of delayed graft function (DGF; odds ratio, 0.68; 95% CI, 0.64-0.72), an association that was stronger among deceased-donor recipients and not present among living-donor recipients. It was also associated with a lower risk of death-censored graft failure (HR, 0.81; 95% CI, 0.74-0.88), which was largely attenuated after adjustment for DGF. There was no association with all-cause graft failure (HR, 0.96; 95% CI, 0.91-1.00).

The investigators noted that intent to pursue preemptive transplantation is not recorded in the registry, that only transplanted patients were included, and that residual confounding cannot be excluded. They concluded that the findings challenge presumed survival advantages and do not support prioritizing preemptive status in deceased-donor allocation for that reason. They suggested that preemptive strategies focus on preventing early graft dysfunction and optimizing use of high-risk kidneys rather than on an expected mortality benefit.

Source: Rampersad C, Liew IT, Liu K, et al. Survival outcomes following preemptive vs nonpreemptive kidney transplantation. JAMA Netw Open. 2026;9(10):e2637964. doi:10.1001/jamanetworkopen.2026.37964