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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO EDITOR Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 4  |  Page : 627-628
Do we still need more data to provide renal transplantation for the CKD patients at or prior to stage 4?


Consultant Nephrologist, King Fahad Specialist Hospital, P.O. Box 15215, Dammam-31444, Saudi Arabia

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How to cite this article:
Abutaleb N. Do we still need more data to provide renal transplantation for the CKD patients at or prior to stage 4?. Saudi J Kidney Dis Transpl 2007;18:627-8

How to cite this URL:
Abutaleb N. Do we still need more data to provide renal transplantation for the CKD patients at or prior to stage 4?. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Jul 16];18:627-8. Available from: http://www.sjkdt.org/text.asp?2007/18/4/627/36526
To the Editor:

It was 1995, when I wrote a letter to an editor (unpublished) suggesting early renal transplantation as a solution to maximize the grafted nephron mass. This suggestion was made as an alternative approach to the original famous idea of maximizing nephron mass by double kidney transplantation. In many occasions, the grafted kidney suffer further intra and post transplantation damage that seems to bring the total grafted nephron mass to below 'the critical level'. This is expected to initiate a self perpetuating chronic allograft dysfunction regardless of the immune response. Utilizing the native remaining nephrons through early transplantation instead of transplanting another kidney seems some­what logical.

Current available data on the overwhel­mingly rapid progressive organ damage in the CKD patients constitute a new strong reason to revive the idea of early trans­plantation. Aggressive approaches to abort the ongoing pathological processes that underlie this high CKD morbidity should be considered. Obviously, only renal transplan­tation among RRT modalities can reverse the uremic milieu and its associated patho­logical process. What is the point in waiting for the CKD patients to reach ESRD in order to receive the definitive available therapy, i.e. renal transplantation? By then, 90% of them have died and missed the chance of receiving such therapy. For the lucky survivors, the damage that has developed in their organ is beyond complete repair.

The talk here is about the extra mile that we need to consider after agreeing on the value of preemptive renal transplantation. Some colleagues may want their patients to taste the suffering on dialysis so that their future compliance with the later immuno­suppressive therapy would be complete. Despite this fear, higher patient and graft survival was established for the preemptive renal transplantation approach. This has occurred despite that this transplantation is carried out within CKD stage 5 at about the time of introducing dialysis therapy. The benefits gained from this approach and also from just decreasing the time on dialysis till transplantation suggests the potentially higher gains that might be expected from intro­ducing transplantation much earlier.

Currently reported morbidity and mortality rates for the CKD patients in stages 3 & 4 justify, I believe, considering those CKD patients for renal transplantation. This would be more obvious for the subgroups with highest risk as the aged and the diabetic patients. It is also likely that early trans­plantation can be justified for those patients with rapid glomerular filtration rate (GFR) loss. Theoretically, this might help relieving the 'maladaptive' compensatory hyperfil­tration response and allow the remaining native nephrons to survive longer. Keith et al reported 5 year mortality of 24.3% and 45.7% in CKD stages 3 & 4, respectively. [1] Only 1.3% of the patients in stage 3 reached ESRD stage during this 5 year follow-up period. "Recent data have shown that CKD patients are 5-10 times more likely to die than to reach ESRD." [2] Despite offering renal transplan­tation at stage 5, it has still provided dramatic reduction in both morbidity and mortality. Compared to those of transplant patients, mortality rates in the dialysis population are 9.6-13.8 times higher for heart disease, 5.2-6.3 times higher for cerebrovascular disease, and 6.1-8.4 times higher for septicemia. [3]

Should we start looking at renal transplan­tation not just as a choice of RRT but as a life saving measure that should not be delayed till missed by the majority of its potential candidates. We need a courageous pros­pective study to address potential benefits of renal transplantation prior to stage 4 on the long term morbidity and mortality of the CKD patients.

 
   References Top

1.Keith DS, Nichols GA, Gullion CM, Brown JB, Smith DH. Longitudinal follow­up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Intern Med 2004; 164:659-63.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.USRDS 2003.  Back to cited text no. 2    
3.USRDS 2006.  Back to cited text no. 3    

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Correspondence Address:
Nasrulla Abutaleb
Consultant Nephrologist, King Fahad Specialist Hospital, P.O. Box 15215, Dammam-31444
Saudi Arabia
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PMID: 17951957

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Abutaleb, N.
Nephrology Dialysis Transplantation. 2008; 23(5): 1766
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