Survival Outcomes Following Preemptive vs Nonpreemptive Kidney Transplantation
9 affiliations
- 1Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- 3Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
- 4Singhealth Duke–NUS Transplant Centre, Singapore Health Services, Singapore, Singapore
- 5Transplant Epidemiology Group (TrEG), Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
- 6Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- 7Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- 8Departments of Medicine and Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- 9London Health Sciences Centre Research Institute, London, Ontario, Canada
Abstract
Importance: Preemptive kidney transplantation (before dialysis) is promoted as optimal therapy for kidney failure, yet evidence of a true survival advantage remains uncertain due to confounding, selection, and lead-time biases.
Objective: To estimate the associations of preemptive vs nonpreemptive kidney transplantation with mortality and graft outcomes using a target trial emulation among transplant recipients.
Design, Setting, and Participants: This retrospective cohort study used data from the Scientific Registry of Transplant Recipients, a nationwide registry of all US kidney transplant centers, from January 1, 2005, to November 30, 2023. Adult first kidney-alone transplant recipients with recorded wait-time start at an estimated glomerular filtration rate (eGFR) of 20 mL/min/1.73 m ² or less were included. Groups were balanced using stabilized inverse probability of treatment weighting (IPTW) to emulate randomization across demographic, clinical, and socioeconomic factors identified by a directed acyclic graph. Analyses were conducted from July to October 2025.
Exposures: Preemptive vs nonpreemptive kidney transplantation, defined by dialysis before transplant.
Main Outcomes and Measures: The primary outcome was all-cause mortality; secondary outcomes were all-cause graft failure, death-censored graft failure, and delayed graft function. IPTW was incorporated for baseline confounding to address selection bias. Weighted Kaplan-Meier curves estimated survival differences; hazard ratios (HRs) and odds ratios (ORs) were derived from weighted left-truncated Cox proportional hazards (to address lead-time bias) and logistic regression models, respectively.
Results: Among 32 770 recipients (15 894 [48.5%] preemptive [mean (SD) age, 53.7 (13.1) years; 7007 (44.1%) female] and 16 876 [51.5%] nonpreemptive [mean (SD) age, 54.5 (13.0) years; 6978 (41.3%) female]) with more than 265 369 person-years of follow-up, 6827 deaths occurred. Preemptive transplantation showed no mortality benefit (HR, 1.02; 95% CI, 0.96-1.07). The weighted survival differences were approximately 1% to 2% annually. Preemptive transplantation was associated with lower odds of delayed graft function (OR, 0.68; 95% CI, 0.64-0.72) and reduced risk of death-censored graft failure (HR, 0.81; 95% CI, 0.74-0.88), an association largely attenuated after adjustment for delayed graft function. There was no association with all-cause graft failure (HR, 0.96; 95% CI, 0.91-1.00).
Conclusions and Relevance: In this study, preemptive transplantation was not associated with improved patient survival but was associated with lower rates of delayed graft function and death-censored graft failure. Findings challenge presumed survival advantages and suggest preemptive strategies should focus on preventing early graft dysfunction and optimizing use of high-risk kidneys rather than expected mortality benefit.
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BibTeX
@article{rampersad2026survival,
title = {{Survival Outcomes Following Preemptive vs Nonpreemptive Kidney Transplantation}},
author = {Christie Rampersad and Ian Tatt Liew and Kuan Liu and Georgina L. Irish and Philip A. Clayton and Greg Knoll and Kyla Naylor and S. Joseph Kim},
journal = {JAMA Network Open},
year = {2026},
month = oct,
doi = {10.1001/jamanetworkopen.2026.37964},
url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854971},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Survival Outcomes Following Preemptive vs Nonpreemptive Kidney Transplantation
AU - Christie Rampersad
AU - Ian Tatt Liew
AU - Kuan Liu
AU - Georgina L. Irish
AU - Philip A. Clayton
AU - Greg Knoll
AU - Kyla Naylor
AU - S. Joseph Kim
PY - 2026
DA - 2026/10/08
JO - JAMA Network Open
DO - 10.1001/jamanetworkopen.2026.37964
UR - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854971
AB - Importance: Preemptive kidney transplantation (before dialysis) is promoted as optimal therapy for kidney failure, yet evidence of a true survival advantage remains uncertain due to confounding, selection, and lead-time biases. Objective: To estimate the associations of preemptive vs nonpreemptive kidney transplantation with mortality and graft outcomes using a target trial emulation among transplant recipients. Design, Setting, and Participants: This retrospective cohort study used data from the Scientific Registry of Transplant Recipients, a nationwide registry of all US kidney transplant centers, from January 1, 2005, to November 30, 2023. Adult first kidney-alone transplant recipients with recorded wait-time start at an estimated glomerular filtration rate (eGFR) of 20 mL/min/1.73 m ² or less were included. Groups were balanced using stabilized inverse probability of treatment weighting (IPTW) to emulate randomization across demographic, clinical, and socioeconomic factors identified by a directed acyclic graph. Analyses were conducted from July to October 2025. Exposures: Preemptive vs nonpreemptive kidney transplantation, defined by dialysis before transplant. Main Outcomes and Measures: The primary outcome was all-cause mortality; secondary outcomes were all-cause graft failure, death-censored graft failure, and delayed graft function. IPTW was incorporated for baseline confounding to address selection bias. Weighted Kaplan-Meier curves estimated survival differences; hazard ratios (HRs) and odds ratios (ORs) were derived from weighted left-truncated Cox proportional hazards (to address lead-time bias) and logistic regression models, respectively. Results: Among 32 770 recipients (15 894 [48.5%] preemptive [mean (SD) age, 53.7 (13.1) years; 7007 (44.1%) female] and 16 876 [51.5%] nonpreemptive [mean (SD) age, 54.5 (13.0) years; 6978 (41.3%) female]) with more than 265 369 person-years of follow-up, 6827 deaths occurred. Preemptive transplantation showed no mortality benefit (HR, 1.02; 95% CI, 0.96-1.07). The weighted survival differences were approximately 1% to 2% annually. Preemptive transplantation was associated with lower odds of delayed graft function (OR, 0.68; 95% CI, 0.64-0.72) and reduced risk of death-censored graft failure (HR, 0.81; 95% CI, 0.74-0.88), an association largely attenuated after adjustment for delayed graft function. There was no association with all-cause graft failure (HR, 0.96; 95% CI, 0.91-1.00). Conclusions and Relevance: In this study, preemptive transplantation was not associated with improved patient survival but was associated with lower rates of delayed graft function and death-censored graft failure. Findings challenge presumed survival advantages and suggest preemptive strategies should focus on preventing early graft dysfunction and optimizing use of high-risk kidneys rather than expected mortality benefit.
SN - 2574-3805
ER -