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. For many people with end-stage renal disease (ESRD), a kidney transplant is the best path forward-not just for survival, but for living better. It’s not a simple fix, though. There are strict rules to qualify, a major surgery to get through, and a lifetime of care afterward. If you’re thinking about a transplant, here’s what you really need to know.

Who Can Get a Kidney Transplant?

Not everyone with kidney failure is a candidate. The goal isn’t just to replace the organ-it’s to make sure the transplant actually works and that you can stick with the treatment. Most transplant centers require you to have end-stage renal disease, meaning your kidneys are working at 15% or less of normal capacity. That’s measured by your glomerular filtration rate (GFR), which should be 15 mL/min/1.73m² or lower. Some centers, like Mayo Clinic, may consider you if your GFR is up to 20 mL/min, especially if it’s dropping fast or you have a living donor ready.

Age alone doesn’t disqualify you. While Vanderbilt University Medical Center sees age 75 and older as a potential risk, UCLA doesn’t set a hard cutoff. Instead, they look at your overall health: heart function, lung capacity, strength, and mental clarity. Frailty matters more than years. Tests like grip strength, walking speed, and how easily you get tired help doctors decide if your body can handle the surgery and recovery.

Obesity is another major barrier. A BMI over 35 raises your risk of complications-wound infections, longer hospital stays, and even graft failure. A BMI above 45 is often an automatic disqualifier at places like Vanderbilt and Mayo Clinic. If you’re overweight, many centers require you to lose weight first. Losing even 10-15% of your body weight can make you eligible.

Your heart and lungs have to be strong enough for surgery. If you have severe pulmonary hypertension-where pressure in your lung arteries is over 70 mm Hg-you won’t qualify. Same with needing oxygen all the time. Heart problems? You’ll need an echocardiogram and stress test. Most centers want your heart’s pumping ability (ejection fraction) to be at least 35-40%.

What Disqualifies You?

Some conditions make a transplant too risky. These are absolute no-gos:

• Active cancer: If your cancer isn’t in remission or could come back, you’ll wait. Most centers require at least 2-5 years of being cancer-free, depending on the type.
• Untreated infections: Hepatitis B or C with active virus in your blood, or HIV with a CD4 count below 200 or a detectable viral load, will block you.
• Substance abuse: Ongoing alcohol or drug use? You’ll need to prove you’ve been clean for at least 6 months, often with counseling and random drug tests.
• Severe mental illness: If you can’t manage your own meds or follow up with doctors due to untreated depression, psychosis, or dementia, you’re not a candidate.

It’s not about being perfect-it’s about being able to survive the transplant and stick with the lifelong care. That’s why centers also check your support system. Do you have someone who can drive you to appointments, remind you to take pills, and call your doctor if something feels off? Penn Medicine and Nebraska Medicine require a designated care partner. No backup? You might need to build one before moving forward.

The Surgery: What Happens During the Procedure?

The surgery itself takes 3 to 4 hours. You’ll be under general anesthesia. The surgeon places the new kidney in your lower belly-not where your old kidneys are. Your own kidneys usually stay in place unless they’re causing infections, high blood pressure, or pain.

The new kidney’s blood vessels are connected to your main artery and vein. The ureter-the tube that carries urine-is attached to your bladder. It sounds complex, but surgeons do this thousands of times a year. In most cases, the kidney starts making urine right away. But about 20% of kidneys from deceased donors don’t work immediately. That’s called delayed graft function. You might need dialysis for a few days or weeks until it kicks in.

Living donor transplants are the gold standard. They have better outcomes because the kidney is healthy, fresh, and matched perfectly. The National Kidney Registry reports a 97% one-year survival rate for living donor kidneys, compared to 93% for deceased donor kidneys. The donor can live a normal life with one kidney. There’s no evidence that donating shortens life or increases future kidney disease risk.

Life After Transplant: The Real Challenge

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

You’ll need lifelong immunosuppressants-meds that stop your immune system from attacking the new kidney. The standard combo? A calcineurin inhibitor (like tacrolimus), an antiproliferative drug (like mycophenolate), and a steroid (like prednisone). Some people get extra drugs at first, like antibodies given during surgery to prevent early rejection.

These drugs aren’t optional. Miss a dose? You risk rejection. Take too much? You get infections, diabetes, or even cancer. Side effects are real: tremors, high blood pressure, weight gain, hair loss, and increased risk of skin cancer. You’ll need regular blood tests to keep your drug levels just right.

Follow-up is strict. The first month? Weekly visits. Months 2-6? Monthly. After that? Every 3 months. You’ll always need yearly checkups. Blood pressure, kidney function, and medication levels are tracked forever. Even if you feel fine, skipping appointments can cost you the transplant.

Survival rates tell the story: 95% of living donor transplants work after one year. After five years, 85% are still going strong. Deceased donor kidneys? 92% survive the first year. Five-year survival drops to 78%. That gap isn’t just numbers-it’s quality of life. People who get living donor transplants return to work faster, travel more, and live longer.

New Advances Changing the Game

The system isn’t perfect, but it’s getting better. The Kidney Donor Profile Index (KDPI), used since 2014, helps match kidneys to the right patients. A high-KDPI kidney comes from an older donor or someone with health issues. It might not last as long-but it’s still better than dialysis. A 2022 study in the American Journal of Transplantation showed that even high-KDPI kidneys improve life expectancy by years compared to staying on dialysis.

Researchers are also working on tolerance. The dream? No lifelong drugs. Clinical trials at Stanford and the University of Minnesota are testing ways to train the immune system to accept the new kidney without suppressing it. Early results are promising. Within the next decade, we might see patients off immunosuppressants entirely.

Organ preservation is improving too. New machines that keep donor kidneys alive and oxygenated during transport are boosting success rates, especially for kidneys that used to be considered too risky.

What Comes Next?

If you’re on dialysis or close to it, talk to your nephrologist about a transplant evaluation. Don’t wait until you’re desperate. The process takes months. You’ll need tests, interviews, and sometimes lifestyle changes. But if you qualify, a transplant can give you back years of life you didn’t know you were missing.

It’s not easy. But for thousands of people each year, it’s the best choice they’ve ever made.