BACKGROUND Preemptive transplantation (PTX) utilizes transplantation as the primary renal replacement therapy in the absence of any preceding dialysis. In developing countries, PTX may be a cost-effective option, offering additional benefits to conventional transplantation. METHODS Between 1989 and 1996, 43 patients who underwent live-related PTX were compared with 86 matched controls who underwent transplantation after hemodialysis. Pre- and posttransplant morbidity, and graft and patient survival rates were compared. RESULTS Median follow-up was 15 months in the preemptive group and 20.5 months in the control group. Controls received more transfusions (4.6+/-2.6 vs. 2.4+/-2.3), had higher hepatitis B surface antigen positivity [12 (14.6%) vs. 1 (2.4%)], and more commonly had hepatic dysfunction [5 (5.8%) vs. nil)] in the pretransplant period compared with the preemptive group. Similarly, at 6 months after transplant, the incidence of hepatitis B surface antigen positivity (13 vs. 2) and hepatic dysfunction (18 vs. 3) were higher in the control group compared with the preemptive group. The 1- and 2-year graft (preemptive: 82.8% and 77.3%; controls: 82% and 78%, respectively) and patient (preemptive: 92% and 89.5%; controls: 91% and 89.5%, respectively) survival rates were similar. CONCLUSIONS PTX offers comparable patient and graft survival to conventional transplantation. It eliminates the complications and inconvenience of dialysis. Transfusion requirements, and therefore associated morbidity, are lower. PTX is more cost effective, therefore, it should be a recommended practice in a developing country.