Bengaluru: Kidney transplants are increasingly being considered before patients reach the stage of needing dialysis. The share of pre-emptive transplants has risen from 1-2% before Covid-19 to almost 15%, or roughly one in seven, Dr Mohan Keshavamurthy, principal director, renal sciences, Fortis Hospitals, said. Such patients are usually younger people who want to lead an active life despite kidney failure, he added.A 42-year-old woman in the city with inherited polycystic kidney disease recently received a kidney from her mother before she had to begin dialysis, highlighting the possibility of a pre-emptive transplant. Nephrologists say the approach can spare eligible patients from the burden and complications of dialysis, but it needs early diagnosis, timely evaluation and careful assessment of both the recipient and the living donor.The woman has autosomal dominant polycystic kidney disease (ADPKD), a hereditary condition in which cysts develop in the kidneys and progressively impair their function. Her father died of the same disease, and her brother carries the same genetic defect but has not developed the same degree of illness, said Dr Keshavamurthy.She knew she would eventually need intervention and had a willing donor in her 74-year-old mother. But she was worried about the surgical risk to her mother and hesitated for over two years. Robotic surgery, used for both donor and recipient, helped tip the balance. The family was assured that the mother could go home within a day of surgery, Dr Keshavamurthy said.Dr Prashant G Kedlaya, professor and head of nephrology at St John’s Medical College and Hospital, said the idea is to transplant before complications such as fluid accumulation in the lungs, acidosis or uraemic symptoms make dialysis necessary.Avoiding dialysis has health and economic benefits, he said. “Prolonged dialysis can bring complications related to vascular access, such as fistulas and catheters, and some patients need blood transfusions. Six months of dialysis costs around Rs 1.5 lakh,” he said.Dr Kedlaya said pre-emptive transplants account for around 3-5% of kidney transplants. Dr Ravi Prakash Deshpande, senior consultant nephrologist at NU Hospitals, Mission Road, said, “Patients usually wait until symptoms appear before approaching a doctor. Most are still unaware of preemptive transplantation, and conversations about a transplant typically begin only after they have started dialysis.”Dr Vishwanath S, HOD and consultant nephrology and transplant physician at Manipal Hospital, Old Airport Road, said evaluation can begin when the glomerular filtration rate (GFR), a measure of kidney function, falls to around 15-20 ml/min and the patient is still asymptomatic.“Kidney transplantation generally offers a better quality of life than dialysis,” he said. He added evidence directly comparing graft survival in pre-emptive and post-dialysis transplants is limited, but long-term patient outcomes are generally better with the pre-emptive route.“The procedure is possible only with a willing, suitable living donor,” Dr Vishwanath said. “As of now, patients can register for a deceased-donor transplant only after being on dialysis for three months in India,” he said.Doctors also caution against going too early. “Patients are exposed to immunosuppressive drugs after a transplant, and there is no point in doing a transplant when the GFR is still above 20-30 ml/min,” Dr Vishwanath said. Patients with significant problems in other organs, such as heart disease, also may not be candidates for pre-emptive transplants, Dr Kedlaya added.
