Kidney Transplant: Eligibility, Surgery, and Long-Term Management

When your kidneys fail, life changes. Dialysis keeps you alive, but it doesn’t give you back your life. A kidney transplant can. It’s not a cure, but for most people with end-stage renal disease (ESRD), it’s the best shot at returning to normal activities-working, traveling, spending time with family-without being tied to a machine three times a week.

Who Can Get a Kidney Transplant?

Not everyone with kidney failure qualifies. The goal isn’t just to replace a failing organ-it’s to give you the best chance at long-term survival and quality of life. That means transplant centers screen carefully.

The main requirement is end-stage renal disease, meaning your kidneys are working at 15% or less of normal capacity. This is measured by your glomerular filtration rate (GFR). Most centers require a GFR of 20 mL/min or lower. Some, like Mayo Clinic, may consider patients with a GFR up to 25 mL/min if their kidney function is dropping fast or if they have a living donor ready.

Age isn’t a hard barrier. While Vanderbilt University Medical Center flags age 75+ as a relative contraindication, UCLA doesn’t set an upper limit. Instead, they look at your overall health. A healthy 80-year-old with strong heart function and no other major illnesses has a better chance than a 60-year-old with uncontrolled diabetes and heart disease.

Body weight matters too. Obesity increases surgical risks and reduces transplant success. Mayo Clinic won’t list anyone with a BMI over 45. Vanderbilt considers a BMI of 35-44 a red flag and over 45 an automatic disqualifier. Why? Studies show obese patients have a 35% higher risk of surgical complications and a 20% higher chance of graft failure. Many centers require weight loss before listing.

Your heart and lungs need to be strong enough to handle major surgery. If you have severe pulmonary hypertension-where pressure in the lung arteries hits 50 mm Hg or higher-you’re likely not a candidate. Vanderbilt sets the bar even higher, rejecting anyone with pressures above 70 mm Hg. If you’re on long-term oxygen because of COPD or other lung disease, most centers will say no. Your heart’s pumping strength, measured by ejection fraction, usually needs to be above 35-40%.

What Disqualifies You?

Some conditions are absolute barriers. You can’t get a transplant if you have:

• Active cancer that hasn’t been treated or is likely to return. Most centers require at least 2-5 years of remission, depending on the cancer type.
• Untreated, ongoing infections like tuberculosis or hepatitis B with active viral replication.
• Uncontrolled substance abuse-alcohol, opioids, methamphetamine. Recovery and sobriety for at least six months are typically required.
• Severe, untreated mental illness that would make it impossible to take daily medications.
• HIV with a CD4 count under 200 or a detectable viral load. (Note: HIV-positive patients can now receive transplants in many centers, but only if their virus is well-controlled.)

The National Health Service Blood and Transplant in the UK puts it simply: you must be well enough to survive surgery and have a realistic chance of the transplant working. It’s not about being perfect-it’s about being strong enough to handle the journey ahead.

The Evaluation Process

Getting listed isn’t just a blood test and a quick chat. It’s a months-long process that looks at every part of your life.

You’ll go through:

• Full blood work, including tissue typing to match you with a donor
• Cancer screenings-colonoscopy, mammogram, skin checks
• Chest X-ray and EKG
• Tests for hepatitis, HIV, and other viruses
• Heart tests like echocardiograms or stress tests, especially if you’re over 50
• Pulmonary function tests if you have breathing issues

Psychological and social evaluations are just as important. Can you manage daily medications? Do you have someone to drive you to appointments? Are you mentally prepared for lifelong follow-up? Penn Medicine and Nebraska Medicine both require a designated care partner-someone who will help you remember pills, notice warning signs, and call the doctor when something’s off.

For older patients, frailty is assessed using tools like the Fried criteria: unintentional weight loss, exhaustion, weak grip strength, slow walking speed, and low physical activity. If you score high on frailty, your chances drop-even if your organs are otherwise healthy.

What Happens During Surgery?

The surgery itself takes 3 to 4 hours. You’re under general anesthesia. The surgeon places the new kidney in your lower abdomen, connects its blood vessels to your iliac artery and vein, and attaches the ureter to your bladder. Your own kidneys are usually left in place unless they’re causing pain, infection, or high blood pressure.

The new kidney often starts working right away. In fact, many patients pee within hours. But don’t be surprised if it doesn’t. About 20% of kidneys from deceased donors take a few days to start producing urine fully. This is called delayed graft function. You might need dialysis for a week or two while it wakes up. It’s not a sign of failure-it’s a common delay.

Living donor transplants tend to work faster and last longer. Why? The kidney comes from a healthy person, is transplanted immediately after removal, and doesn’t sit in cold storage. The kidney’s “cold ischemia time” is zero.

Life After Transplant: The Real Challenge

The surgery is just the beginning. The real work starts after you wake up.

You’ll take immunosuppressants for the rest of your life. These drugs stop your immune system from attacking the new kidney. Common regimens include:

• Tacrolimus or cyclosporine (calcineurin inhibitors)
• Mycophenolate mofetil or azathioprine (antiproliferatives)
• Prednisone (a steroid, often tapered over time)

Some patients get induction therapy-strong antibodies given right after transplant to reduce early rejection risk.

These drugs save your kidney, but they come with side effects. You might gain weight, develop high blood pressure, get diabetes, or have higher risks of infections and skin cancer. That’s why follow-up is non-negotiable.

In the first month, you’ll be at the clinic weekly. Then monthly for the next 3-6 months. After that, quarterly visits. And every year, you’ll get blood tests, urine tests, and sometimes a kidney biopsy to check for hidden rejection.

The numbers don’t lie. One-year graft survival is 95% for living donor transplants and 92% for deceased donor ones. Five-year survival? 85% for living, 78% for deceased. Compare that to dialysis, where only about half of patients are alive after five years.

What’s New in Kidney Transplantation?

The field is evolving fast. One big advance is the Kidney Donor Profile Index (KDPI). This score, used since 2014, helps match kidneys with the longest expected life to the patients who need them most. A low KDPI (under 20%) means a kidney from a young, healthy donor. A high KDPI (over 85%) means an older donor or one with health issues like high blood pressure.

You might think: “Why take a kidney with a high KDPI?” But studies show even these kidneys give patients a much better chance than staying on dialysis. A 60-year-old with a high-KDPI kidney lives longer and feels better than if they waited for a perfect match.

Living donation is growing. More people are choosing to donate a kidney to a friend, family member, or even a stranger through paired exchange programs. The National Kidney Registry reports 97% one-year survival for living donor transplants-better than any other type.

Research is now focused on tolerance. Can we teach the immune system to accept the new kidney without lifelong drugs? Early trials at Stanford and the University of Minnesota are showing promise. Some patients have successfully reduced or stopped immunosuppressants after years of stable function. This could change everything.

What to Expect in the Long Run

You’ll need to be your own best advocate. Take your pills every day, even when you feel great. Skip the grapefruit-it interferes with tacrolimus. Watch your salt and protein intake. Stay active. Get vaccinated. Avoid people who are sick.

You’ll have good days and bad days. Maybe you’ll have a flare-up of high blood pressure. Maybe you’ll get a urinary tract infection. Maybe you’ll worry the kidney is failing. These are normal fears. But with regular monitoring, most problems are caught early and treated.

The goal isn’t perfection. It’s more time. More energy. More moments with your grandkids. More walks in the park. More mornings without exhaustion.

A kidney transplant doesn’t erase kidney disease. But it gives you back your life.