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Does pre-emptive transplantation versus post start of dialysis transplantation with a kidney from a living donor improve outcomes after transplantation? A systematic literature review and position statement by the Descartes Working Group and ERBP

Nephrol Dial Transplant. 2016 May;31(5):691-7 doi: 10.1093/ndt/gfv378.

Abstract

This position statement brings up guidance on pre-emptive kidney transplantation from living donors. The provided guidance is based on a systematic review of the literature.

CET Conclusion

Reviewer:	Mr Simon Knight, Centre for Evidence in Transplantation, The Royal College of Surgeons of England.
Conclusion:	This guideline from the Descartes Working Group incorporates a systematic review comparing the results of pre-emptive live-donor renal transplantation to those of live-donor transplantation after a period on dialysis. The authors identified 29 papers meeting their inclusion criteria, all of which reported retrospective observational cohort studies. Due to the nature of the evidence, they performed a narrative analysis of the data and found that around half of studies demonstrated improvements in patient and graft survival or reductions in the risk of acute rejection. There was no evidence to suggest differences in outcome relating to pre-transplant GFR. On the basis of the identified data, the authors recommend pre-emptive transplantation where possible, with the timing designed to avoid dialysis as close as possible to the need to start. The guidance provided is obviously limited by the high risk of bias in the included observational studies – the authors recognise that the population characteristics of those receiving a pre-emptive transplant are likely very different to those receiving a transplant whilst on dialysis. In general, the article is well written, the methodology sound, and the limitations are well described. The only aspect perhaps missing is a table to show the numbers and characteristics of patients included in each study.

Reviewer:

Mr Simon Knight, Centre for Evidence in Transplantation, The Royal College of Surgeons of England.

Conclusion:

This guideline from the Descartes Working Group incorporates a systematic review comparing the results of pre-emptive live-donor renal transplantation to those of live-donor transplantation after a period on dialysis. The authors identified 29 papers meeting their inclusion criteria, all of which reported retrospective observational cohort studies. Due to the nature of the evidence, they performed a narrative analysis of the data and found that around half of studies demonstrated improvements in patient and graft survival or reductions in the risk of acute rejection. There was no evidence to suggest differences in outcome relating to pre-transplant GFR. On the basis of the identified data, the authors recommend pre-emptive transplantation where possible, with the timing designed to avoid dialysis as close as possible to the need to start. The guidance provided is obviously limited by the high risk of bias in the included observational studies – the authors recognise that the population characteristics of those receiving a pre-emptive transplant are likely very different to those receiving a transplant whilst on dialysis. In general, the article is well written, the methodology sound, and the limitations are well described. The only aspect perhaps missing is a table to show the numbers and characteristics of patients included in each study.

Study Details

Aims:	To provide guidance on pre-emptive kidney transplantation from living donors.
Interventions:	A systematic review of the literature was conducted which included observational data, mainly coming from single centre or regional registries, performed after 1990 providing data on aspects of pre-emptive living donation. The databases Medline and Embase were searched on 16 May 2013.
Participants:	29 retrospective observational cohort studies (26 published articles and 3 abstracts) were incuded.
Outcomes:	The primary outcomes measured were patient survival, graft survival and acute rejection rate.
Follow Up:	Not described

Metadata

Funding:	none described
Publication type:	Review, Systematic Review
Organ:	Kidney
Language:	English
Author email:	guidelines@era-edta
MeSH terms:	Humans; Kidney Failure, Chronic; Kidney Transplantation; Living Donors; Renal Dialysis