The Future of Dialysis and Kidney Xenotransplantation: Promise, Cost, and Barriers to Implementation

Background/Objectives: Dialysis remains essential for patients with kidney failure but replaces only part of kidney function and imposes a substantial treatment burden. Gene-edited porcine kidneys offer a possible additional source of organs, although clinical experience remains limited. This review examines advances in dialysis and kidney xenotransplantation, their evidence base, costs, and barriers to clinical use. Methods: We undertook a targeted narrative update of clinical and technological reports, economic studies, and regulatory material. Randomized trials were considered separately from observational studies, target trial emulations, individual cases, preclinical experiments, and economic projections. Results: Randomized evidence supports a survival benefit of high-volume hemodiafiltration in suitable patients, although individual trials have differed and achieved convection volume is influenced by patient and treatment characteristics. Wearable dialysis and sorbent-assisted peritoneal dialysis remain at an early stage of clinical evaluation. Porcine kidney xenografts have provided dialysis independence in individual recipients, but rejection, endothelial injury, infection, and the burden of immunosuppression remain unresolved. Human kidney transplantation is generally favorable over longer horizons in eligible patients; its value depends on the setting. Xenotransplantation costs and long-term cost-effectiveness remain uncertain. Implementation requires financing, trained staff, reliable supply chains, and informed consent that addresses prolonged surveillance and cultural concerns. Conclusions: Improved dialysis and kidney xenotransplantation are likely to have complementary roles. Adoption should depend on demonstrated clinical benefit, sustainable costs, and equitable access, while prevention and early treatment of chronic kidney disease remain priorities.