Abecassis M et al. (2008) Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQI™) conference. Clin J Am Soc Nephrol 3: 471–480

Only 2.5% of patients with end-stage renal disease undergo kidney transplantation as initial renal replacement therapy, despite evidence that transplantation is most effective when implemented before initiation of long-term dialysis. Participants in a recent conference convened by the National Kidney Foundation have examined how to increase the use of pre-emptive kidney transplantation for patients with advanced chronic kidney disease (CKD).

The 52 conference attendees (who comprised representatives from transplantation centers, dialysis providers, and payers) have recommended that patients with end-stage renal disease who are seen by a nephrologist at least 6 months before beginning dialysis should be referred for transplantation before or at the same time as the creation of vascular access, and that the optimum timing for pre-emptive transplantation is in most instances late in stage 4 CKD or early in stage 5 CKD but should be individualized to the patient. Patients who have stage 5 CKD or who are about to begin dialysis should be referred immediately for transplantation. Education highlighting pre-emptive transplantation as a possible renal replacement modality should be provided to patients with stage 3 or early stage 4 CKD. Primary care physicians should be better trained to recognize CKD; all patients should be referred to a nephrologist before they reach an estimated glomerular filtration rate of <30 ml/min/1.73 m2 (early stage 4 CKD).

The participants also assessed the financial hurdles that impede access to pre-emptive transplantation and recommend that the eligibility criteria, coverage, and reimbursement structure of Medicare and employee group health plans should be standardized to promote early access to transplantation services.