{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T15:51:27Z","timestamp":1791474687880,"version":"4.3.4"},"reference-count":21,"publisher":"American Medical Association (AMA)","issue":"10","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To estimate the associations of preemptive vs nonpreemptive kidney transplantation with mortality and graft outcomes using a target trial emulation among transplant recipients.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n \n 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\n 2<\/jats:sup>\n 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.\n <\/jats:p>\n <\/jats:sec>\n \n Exposures<\/jats:title>\n Preemptive vs nonpreemptive kidney transplantation, defined by dialysis before transplant.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Among 32\u202f770 recipients (15\u202f894 [48.5%] preemptive [mean (SD) age, 53.7 (13.1) years; 7007 (44.1%) female] and 16\u202f876 [51.5%] nonpreemptive [mean (SD) age, 54.5 (13.0) years; 6978 (41.3%) female]) with more than 265\u202f369 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).<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2026.37964","type":"journal-article","created":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T15:00:35Z","timestamp":1791471635000},"page":"e2637964","source":"Crossref","is-referenced-by-count":0,"title":["Survival Outcomes Following Preemptive vs Nonpreemptive Kidney Transplantation"],"prefix":"10.1001","volume":"9","author":[{"given":"Christie","family":"Rampersad","sequence":"first","affiliation":[{"name":"Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada"},{"name":"Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ian Tatt","family":"Liew","sequence":"additional","affiliation":[{"name":"Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore"},{"name":"Singhealth Duke\u2013NUS Transplant Centre, Singapore Health Services, Singapore, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kuan","family":"Liu","sequence":"additional","affiliation":[{"name":"Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georgina L.","family":"Irish","sequence":"additional","affiliation":[{"name":"Transplant Epidemiology Group (TrEG), Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia"},{"name":"Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philip A.","family":"Clayton","sequence":"additional","affiliation":[{"name":"Transplant Epidemiology Group (TrEG), Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia"},{"name":"Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Greg","family":"Knoll","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kyla","family":"Naylor","sequence":"additional","affiliation":[{"name":"Departments of Medicine and Epidemiology and Biostatistics, Western University, London, Ontario, Canada"},{"name":"London Health Sciences Centre Research Institute, London, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S. 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