*Purpose: In the wake of the Executive Order on Advancing American Kidney Health, it is essential to fully examine the current care paradigm for chronic kidney disease (CKD) patients as further policy changes may be required to promote more accessible, cost effective care. Preemptive kidney transplantation provides the best health outcomes and quality of life at the lowest cost compared to transplantation after dialysis initiation.

*Methods: We retrospectively examined transplant evaluation data from kidney transplant candidates from June 2016 to June 2018 at a single center to quantify the prevalence of preemptive status at time of initial transplantation evaluation. The dataset included follow-up data through December 2019. A logistic regression model was used to quantify the relationship between preemptive evaluation status and living donation transplantation.

*Results: A total of 1892 initial evaluations were conducted during the study period; 24 percent of those evaluations were of preemptive transplant patients (n=457). 914 total initial evaluations were presented to the medical review board during the study period, and 862 of those were approved with no statistically significant difference in the approval rates between groups. There were 436 kidney transplants that resulted from the initial evaluations during the same three-year period, and 31 percent were preemptively evaluated. 41 percent of the total transplants during this time period were living donor kidney transplants (LDKT, n=179); only 39 percent of the total LDKT patients were evaluated preemptively (n=70). Patients who were preemptively evaluated for transplantation were 1.56 times as likely to have received a transplant during the study period (p=.0003, 1.22-1.95).

*Conclusions: Despite extensive documentation on the benefits of preemptive kidney transplantation, evidence continues to show an underutilization of this treatment. “Preemptive kidney transplant remains an unrealized goal for the majority of recipients (1),” and our results supports this assertion. This is especially true for Medicare patients and minority populations. Future research should focus on understanding the the decision process of CKD patients in determining their course of treatment. Intervening earlier may be appropriate as there is a disparate rate of preemptive initial evaluations for transplantation. Further examination of why living donor transplantations aren’t consistently sought preemptively also seems particularly appropriate. (1) doi:10.1097/TP.0000000000000944

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