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

What Is a Kidney Transplant?

A kidney transplant is when a healthy kidney from a donor replaces a failing one. It’s not a cure, but it’s the closest thing to one for people with end-stage renal disease (ESRD). Unlike dialysis, which only does part of what kidneys do, a transplant lets you live more like you did before your kidneys failed. You won’t need to spend hours hooked up to a machine three times a week. You’ll have more energy, fewer dietary restrictions, and a much better chance of living longer.

The first successful kidney transplant happened in 1954 between identical twins. Since then, the procedure has become routine. In 2023, around 27,000 kidney transplants were done in the U.S. alone. But over 100,000 people are still waiting. The biggest hurdle? Finding a match - and being healthy enough to get one.

Who Qualifies for a Kidney Transplant?

You don’t automatically qualify just because your kidneys are failing. Transplant centers have strict rules because the surgery is major, and you’ll need to take anti-rejection drugs for life. If you’re not a good candidate, the risks outweigh the benefits.

The main requirement is end-stage renal disease. That means your glomerular filtration rate (GFR) is 20 mL/min or lower. Some centers will consider you if your GFR is up to 25 mL/min - especially if your kidney function is dropping fast or you have a living donor ready. Most people on the list are already on dialysis, or about to start.

Age isn’t a hard cutoff. Some centers won’t transplant anyone over 75. Others look at your overall health, not your birthday. A healthy 80-year-old with strong heart and lungs might be a better candidate than a 60-year-old with diabetes and heart disease.

Body Weight and Health Risks

Obesity is one of the biggest barriers. A BMI over 45 usually means you’re disqualified. Some centers won’t even consider you if your BMI is above 35. Why? Extra weight makes surgery riskier. It increases the chance of infection, poor wound healing, and even kidney failure after transplant. One study showed obese patients have a 35% higher risk of surgical complications and a 20% higher chance of losing the new kidney.

If you’re overweight, many centers require you to lose weight before being listed. That’s not a punishment - it’s about giving you the best shot at long-term success.

Heart and Lung Health Matter Too

Your heart and lungs have to be strong enough to handle surgery and recovery. If you have severe pulmonary hypertension - meaning high blood pressure in your lungs - you won’t qualify. Some centers set the limit at 70 mm Hg. If you need oxygen all the time because of COPD, you’re likely not a candidate.

Heart tests are routine. You’ll get an echocardiogram, a stress test, and sometimes a cardiac catheter. Your heart’s pumping strength (ejection fraction) needs to be at least 35-40%. If it’s lower, you might need a heart procedure first.

The Evaluation Process

Getting on the transplant list isn’t a quick visit to the doctor. It’s a full medical and social audit.

• You’ll have blood tests for infections like HIV, hepatitis, and CMV.
• Tissue typing checks how well your body might accept a donor kidney.
• Cancer screening is mandatory. If you’ve had cancer, you usually need to be in remission for at least 2-5 years, depending on the type.
• A chest X-ray and EKG check your lungs and heart.
• Psychological evaluation looks at your mental health and ability to follow complex care routines.
• Frailty tests measure strength, walking speed, and energy levels - especially for older adults.

You’ll also need a care partner. This person helps you take your meds, drives you to appointments, and calls the team if something goes wrong. No support system? You won’t be listed. Transplant isn’t a solo mission.

What Disqualifies You?

Some things are absolute deal-breakers:

• Active cancer that’s likely to come back
• Untreated HIV with a low CD4 count or high viral load
• Active hepatitis B with detectable virus
• Current drug or alcohol abuse
• Severe, untreated mental illness that makes you unable to follow your medication schedule

Even if you’ve quit drugs or alcohol, you’ll need at least 6 months of sobriety before being considered. This isn’t about judging you - it’s about survival. Missing one dose of anti-rejection medicine can mean losing the transplant.

What Happens During Surgery?

The operation takes 3 to 4 hours. You’re under general anesthesia. The surgeon places the new kidney in your lower belly, connects its blood vessels to your arteries and veins, and attaches the ureter to your bladder. Your own kidneys? They’re usually left in place unless they’re infected, causing pain, or raising blood pressure.

Most new kidneys start working right away. But about 1 in 5 - especially those from deceased donors - take a few days to start making urine. That’s called delayed graft function. You might need dialysis for a short time after surgery. It’s not a failure. It’s common.

Life After the Transplant

You’re not done after surgery. The real work begins now.

You’ll take immunosuppressants every single day, for the rest of your life. These drugs stop your immune system from attacking the new kidney. Common ones include tacrolimus, mycophenolate, and steroids. Missing even one dose can trigger rejection.

Side effects are real. You might gain weight, get high blood sugar, develop high cholesterol, or have shaky hands. Some people get skin cancer from long-term use. That’s why you need regular check-ups.

Follow-up is strict:

• Weekly visits for the first month
• Monthly for the next 3-6 months
• Every 3 months after that
• Once a year for life

Blood tests check kidney function and drug levels. Biopsies might be done if there’s concern about rejection. You’ll also get annual skin checks and cancer screenings.

Success Rates and Long-Term Outlook

Transplants work. A lot better than dialysis.

One year after transplant, 95% of living donor kidneys are still working. For deceased donor kidneys, it’s 92%. Five years out, 85% of living donor kidneys and 78% of deceased donor kidneys are still going strong. Your chance of living five years after a transplant is about 85%. On dialysis? Only 50%.

Living donors are the gold standard. Their kidneys last longer, work better, and have fewer complications. The National Kidney Registry reports a 97% one-year survival rate for living donor transplants.

New Advances and What’s Coming

Technology is improving outcomes. The Kidney Donor Profile Index (KDPI) helps match kidneys to the right patients. A kidney from an older donor with high KDPI might seem risky - but it’s still better than staying on dialysis.

Researchers are working on ways to reduce or eliminate lifelong immunosuppression. Some clinical trials are testing tolerance-inducing therapies - training the immune system to accept the new kidney without drugs. If this works, it could change everything.

Organ preservation is getting better too. New cooling methods keep kidneys alive longer after donation, giving more time to find the right match.

What If the Transplant Fails?

It happens. About 1 in 4 transplants fail within 10 years. Reasons include rejection, infection, or side effects from meds.

If your transplant fails, you go back to dialysis. You can be re-listed for another transplant. Many people get a second, even a third transplant. Each one gives you more time and better quality of life.

Final Thoughts

A kidney transplant isn’t easy. It’s a long road with strict rules, daily meds, and lifelong monitoring. But for most people, it’s worth it. You get your life back - more freedom, more energy, more time with family.

If you’re on dialysis or close to it, talk to your nephrologist about transplant. Get evaluated. Even if you’re turned down now, you might qualify later. Weight loss, quitting smoking, or managing your blood pressure could open the door. Don’t give up.