The comparator at a kidney offer

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Dear Editor,

Hellemans and colleagues provide useful estimates of survival after deceased donor kidney transplantation compared with continued dialysis.¹ The linked editorial frames the clinical question as whether to accept the kidney being offered now or remain on dialysis and wait for another offer.² We are not sure that the study directly estimates that comparison.

In the hypothetical target trial, the control strategy is no kidney transplant now or in the future. In the emulation, patients who remain waitlisted and on dialysis during the same month form the control group, and they are censored if they later receive a transplant. The comparison is therefore transplantation versus a sustained no-transplant strategy, rather than acceptance versus decline of the same kidney offer.¹

That difference matters because declining an organ does not close the transplant pathway. A patient may continue waiting, may deteriorate or die while waiting, or may later receive another kidney of different quality. The linked editorial itself recognises this trade-off.²

This is particularly relevant when the expected survival advantage is uncertain. At age 75, the estimated hazard ratio for ECD/DCD transplantation versus continued dialysis was 0.97 (95% CI 0.70 to 1.33).¹

The study provides useful estimates for transplantation versus sustained dialysis. We would be cautious, however, about using them as if they directly answered whether to accept the kidney currently offered or continue waiting for another one.

References

1. Hellemans R, Chesnaye NC, Kramer A, et al. Survival benefit of deceased donor kidney transplantation versus continued dialysis: international target trial emulation. BMJ 2026;394:e100624. doi:10.1136/bmj-2026-100624.
2. Kaewput W, Patel M. Kidney transplantation in older adults. BMJ 2026;394:e100831. doi:10.1136/bmj-2026-100831.

No competing Interests: YesThe following competing Interests: Electronic Publication Date: Saturday, September 19, 2026 - 03:12AI use: No, I have not used AIHighwire Comment Subject:

Survival benefit of deceased donor kidney transplantation versus continued dialysis: international target trial emulation

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The comparator at a kidney offer

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Survival benefit of deceased donor kidney transplantation versus continued dialysis: international target trial emulation

Check this box if you would like your letter to appear anonymously:: Last Name: QuFirst name and middle initial: LiangchenEmail:

qulc5682@enzemed.com

Address: 150 Ximen Street, Linhai, Zhejiang 317000, ChinaOccupation: DoctorAffiliation: Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province BMJ: Additional Article Info: Rapid response