NephrologyTier 2Topic

Renal transplantation issues - importance of anticipating future need for dialysis or transplant in patients with progressive CKD

Why plan early

Pre-emptive planning for renal replacement therapy in progressive CKD - anticipating the need for transplantation (and/or dialysis access) well before it becomes urgent, since both pathways have long lead times
Pre-emptive transplantation (before dialysis is ever started) has the best outcomes of any RRT pathway

Living donor transplant evaluation and workup commonly takes months; deceased donor waiting lists commonly run years - both far exceed the time available if referral is delayed until dialysis is imminent

Late referral forces dialysis initiation via a catheter without a mature access, and forecloses the option of a pre-emptive transplant - both associated with worse outcomes than a planned pathway

KDOQI/KDIGO: refer for transplant evaluation 6-12 months before anticipated dialysis need, to allow time for living donor identification/workup
Pre-emptive transplant listing is generally considered from eGFR <20 mL/min/1.73m2 (or earlier with symptoms), with transplantation itself occurring around eGFR <10 or with uraemic symptoms
Education on all RRT modalities (dialysis and transplant) is recommended from eGFR <=30 (CKD stage G4)

Parallel-track planning - transplant workup and dialysis access planning proceed together in progressive CKD, since the actual RRT need date is often uncertain
Early identification of a potential living donor (family/partner screening) is the single highest-yield step, given living donor transplantation offers the best outcomes and shortest wait

Patients who reach dialysis without prior transplant planning face a longer subsequent wait (workup starts from scratch) and lose the option of a pre-emptive transplant

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