The impact of transplantation on survival with kidney failure.

Although the growth in the incidence and prevalence of ESKD has slowed, there will nevertheless be a substantial increase in the number of patients over the next decade. Indeed, between 1998 and 2010 there will be a doubling in the number of patients in the United States treated with renal replacement therapy. There has also been an increase in the number of new transplants carried out every year. Much of the growth in the number of new transplants has been from the growth in living-unrelated donor transplants. Unfortunately, the rate of increase in the number of new transplants has not been enough to keep pace with the growing number of ESKD patients. As a result, the number of patients on the transplant waiting list continues to increase. The inability to offer more ESKD patients transplantation is unfortunate, since transplantation is associated with improved survival. Indeed, analyses of comparable patients who are placed on the transplant waiting list suggest that transplantation reduces the risk of death by roughly 50%. Thus, it is likely that the overall survival of patients with ESKD will improve if a greater proportion of patients receive transplants in a timely manner. Reducing allograft rejection and the need for repeat transplants may help reduce the demand for donor kidneys. However, this is unlikely to have a major effect on the organ shortage, since the number of repeat transplants has been relatively small (and constant) over the past decade. Thus, only if more cadaveric and living-donor kidneys are made available will more ESKD patients enjoy the improved survival of kidney transplantation.