Research Article| Volume 32, ISSUE 5, P505-511, September 2012

Pre-emptive Kidney Transplantation to Improve Survival in Patients With Type 1 Diabetes and Imminent Risk of ESRD


      Despite significant improvements in the treatment of diabetic nephropathy over the past 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease and high mortality once end-stage renal disease develops. Type 1 diabetic patients treated with predialysis (pre-emptive) transplantation have a lower death rate than type 1 diabetic patients treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared with transplantation while on dialysis. In addition, a variety of potential donors can be used, not just young, well-matched family members. Through paired kidney donation, blood group ABO-incompatible transplants and transplants across the barrier of anti-human leukocyte antigen antibodies, diabetic patients can receive living donor kidney transplants even if their intended donor is not a good match for them. Despite these expanded options making living donation possible, only a minority of type 1 diabetic patients receive a pre-emptive kidney transplant. Multiple barriers remain that prevent type 1 diabetic patients from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists, and nephrologists; late referral for transplantation; patient and family misconceptions about timing of transplantation; and who can be a donor. The vast majority of type 1 diabetic patients are listed for kidney transplantation after the initiation of dialysis. Of these patients, thousands subsequently receive a live donor kidney transplant. We believe that the appropriate agencies and societies should address the barriers to pre-emptive kidney transplantation through nationwide educational initiatives and study the causes of failure to be transplanted before dialysis initiation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Seminars in Nephrology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Krolewski A.
        • Bonventre J.V.
        High risk of ESRD in type 1 diabetes: new strategies are needed to retard progressive renal function decline.
        Semin Nephrol. 2012; 32: 407-414
        • Orchard T.J.
        • Secrest A.M.
        • Miller R.G.
        • Costacou T.
        In the absence of renal disease, 20 year mortality risk in type 1 diabetes is comparable to that of the general population: a report from the Pittsburgh epidemiology of diabetes complications study.
        Diabetologia. 2010; 53: 2312-2319
        • Groop P.H.
        • Thomas M.C.
        • Moran J.L.
        • et al.
        The presence and severity of chronic kidney disease predicts all-cause mortality in type 1 diabetes.
        Diabetes. 2009; 58: 1651-1658
        • Rosolowsky E.T.
        • Skupien J.
        • Smiles A.M.
        • et al.
        Risk for ESRD in type 1 diabetes remains high despite renoprotection.
        J Am Soc Nephrol. 2011; 22: 545-553
        • Forsblom C.
        • Harjutsalo V.
        • Thorn L.M.
        • et al.
        Competing-risk analysis of ESRD and death among patients with type 1 diabetes and macroalbuminuria.
        J Am Soc Nephrol. 2011; 22: 537-544
        • Lorenzo V.
        • Martn M.
        • Rufino M.
        • Hernandez D.
        • Torres A.
        • Ayus J.C.
        Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: an observational cohort study.
        Am J Kidney Dis. 2004; 43: 999-1007
        • Perl J.
        • Wald R.
        • McFarlane P.
        • et al.
        Hemodialysis vascular access modifies the association between dialysis modality and survival.
        J Am Soc Nephrol. 2011; 22: 1113-1121
        • Murray M.A.
        • Brunier G.
        • Chung J.O.
        • et al.
        A systematic review of factors influencing decision-making in adults living with chronic kidney disease.
        Patient Educ Couns. 2009; 76: 149-158
      1. The Renal Physicians Association (RPA) and the American Society of Nephrology (ASN) Position on Quality Care at the End of Life.
        (Accessed March 11, 2011)
        • Fassett R.G.
        • Robertson I.K.
        • Mace R.
        • Youl L.
        • Challenor S.
        • Bull R.
        Palliative care in end-stage kidney disease.
        Nephrology (Carlton). 2011; 16: 4-12
        • Germain M.
        • Cohen L.M.
        Renal supportive care: view from across the pond: the United States perspective.
        J Palliat Med. 2007; 10: 1241-1244
        • Douglas C.
        • Murtagh F.E.
        • Chambers E.J.
        • Howse M.
        • Ellershaw J.
        Symptom management for the adult patient dying with advanced chronic kidney disease: a review of the literature and development of evidence-based guidelines by a united kingdom expert consensus group.
        Palliat Med. 2009; 23: 103-110
        • Cohen L.M.
        • Moss A.H.
        • Weisbord S.D.
        • Germain M.J.
        Renal palliative care.
        J Palliat Med. 2006; 9: 977-992
        • US Renal Data System
        USRDS 2008 annual data report: atlas of chronic kidney disease and end-stage renal disease in the united states.
        National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2008
        • Locatelli F.
        • Del Vecchio L.
        • Cavalli A.
        How can prognosis for diabetic ESRD be improved?.
        Semin Dial. 2010; 23: 214-219
      2. Scientific Registry of Transplant Recipients 2009 annual report.
        (Accessed April 19, 2010)
        • Gentry S.E.
        • Montgomery R.A.
        • Segev D.L.
        Kidney paired donation: fundamentals, limitations, and expansions.
        Am J Kidney Dis. 2011; 57: 144
        • Morrissey P.E.
        • Dube C.
        • Gohh R.
        • Yango A.
        • Gautam A.
        • Monaco A.P.
        Good samaritan kidney donation.
        Transplantation. 2005; 80: 1369-1373
        • Mandelbrot D.A.
        • Pavlakis M.
        • Danovitch G.M.
        • et al.
        The medical evaluation of living kidney donors: a survey of US transplant centers.
        Am J Transplant. 2007; 7: 2333-2343
        • Marfo K.
        • Lu A.
        • Ling M.
        • Akalin E.
        Desensitization protocols and their outcome.
        Clin J Am Soc Nephrol. 2011; 6: 922-936
        • Wolfe R.A.
        • Ashby V.B.
        • Milford E.L.
        • et al.
        Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.
        N Engl J Med. 1999; 341: 1725-1730
        • Meier-Kriesche H.U.
        • Port F.K.
        • Ojo A.O.
        • et al.
        Effect of waiting time on renal transplant outcome.
        Kidney Int. 2000; 58: 1311-1317
        • Meier-Kriesche H.U.
        • Kaplan B.
        Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: a paired donor kidney analysis.
        Transplantation. 2002; 74: 1377-1381
        • Mange K.C.
        • Joffe M.M.
        • Feldman H.I.
        Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors.
        N Engl J Med. 2001; 344: 726-731
        • Axelrod D.A.
        • McCullough K.P.
        • Brewer E.D.
        • Becker B.N.
        • Segev D.L.
        • Rao P.S.
        Kidney and pancreas transplantation in the united states, 1999-2008: the changing face of living donation.
        Am J Transplant. 2010; 10: 987-1002
        • Kasiske B.L.
        • Ma J.Z.
        • Louis T.A.
        • Swan S.K.
        Long-term effects of reduced renal mass in humans.
        Kidney Int. 1995; 48: 814-819
        • Kasiske B.L.
        • Snyder J.J.
        • Matas A.J.
        • Ellison M.D.
        • Gill J.S.
        • Kausz A.T.
        Preemptive kidney transplantation: the advantage and the advantaged.
        J Am Soc Nephrol. 2002; 13: 1358-1364
        • Meier-Kriesche H.U.
        • Schold J.D.
        • Srinivas T.R.
        • Reed A.
        • Kaplan B.
        Kidney transplantation halts cardiovascular disease progression in patients with end-stage renal disease.
        Am J Transplant. 2004; 4: 1662-1668
        • Ishani A.
        • Ibrahim H.N.
        • Gilbertson D.
        • Collins A.J.
        The impact of residual renal function on graft and patient survival rates in recipients of preemptive renal transplants.
        Am J Kidney Dis. 2003; 42: 1275-1282
        • Akkina S.K.
        • Connaire J.J.
        • Snyder J.J.
        • Matas A.J.
        • Kasiske B.L.
        Earlier is not necessarily better in preemptive kidney transplantation.
        Am J Transplant. 2008; 8: 2071-2076
        • McCullough K.P.
        • Keith D.S.
        • Meyer K.H.
        • Stock P.G.
        • Brayman K.L.
        • Leichtman A.B.
        Kidney and pancreas transplantation in the united states, 1998-2007: access for patients with diabetes and end-stage renal disease.
        Am J Transplant. 2009; 9: 894-906
        • Abecassis M.
        • Bartlett S.T.
        • Collins A.J.
        • et al.
        Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference.
        Clin J Am Soc Nephrol. 2008; 3: 471-480
        • Cass A.
        • Cunningham J.
        • Snelling P.
        • Ayanian J.Z.
        Late referral to a nephrologist reduces access to renal transplantation.
        Am J Kidney Dis. 2003; 42: 1043-1049
        • Winkelmayer W.C.
        • Glynn R.J.
        • Levin R.
        • Mittleman M.A.
        • Pliskin J.S.
        • Avorn J.
        Late nephrologist referral and access to renal transplantation.
        Transplantation. 2002; 73: 1918-1923
        • Coorey G.M.
        • Paykin C.
        • Singleton-Driscoll L.C.
        • Gaston R.S.
        Barriers to preemptive kidney transplantation.
        Am J Nurs. 2009; 109 (quiz, 38): 28-37
        • Barnieh L.
        • McLaughlin K.
        • Manns B.J.
        • et al.
        Barriers to living kidney donation identified by eligible candidates with end-stage renal disease.
        Nephrol Dial Transplant. 2011; 26: 732-738
        • Pradel F.G.
        • Jain R.
        • Mullins C.D.
        • Vassalotti J.A.
        • Bartlett S.T.
        A survey of nephrologists' views on preemptive transplantation.
        Clin J Am Soc Nephrol. 2008; 3: 1837-1845
        • Ojo A.O.
        • Meier-Kriesche H.U.
        • Hanson J.A.
        • et al.
        The impact of simultaneous pancreas-kidney transplantation on long-term patient survival.
        Transplantation. 2001; 71: 82-90