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

When your kidneys fail, life changes overnight. Dialysis keeps you alive, but it doesn’t give you back your life. For many, a kidney transplant is the only real path to freedom - from needles, schedules, and exhaustion. It’s not a cure, but it’s the closest thing. And for most people who get one, it works. Better than dialysis. Better than anything else.

Who Can Get a Kidney Transplant?

You don’t need to be young or perfect to qualify. But you do need to be well enough to survive the surgery and stick with the lifelong care that follows. The main requirement? End-stage renal disease. That means your kidneys are working at 15% or less of normal capacity. Doctors measure this with your GFR - glomerular filtration rate. If it’s below 20 mL/min, you’re typically eligible. Some centers, like Mayo Clinic, will even consider you if your GFR is up to 25 mL/min, especially if it’s dropping fast or you have a living donor lined up.

Age isn’t a hard barrier. You can be 75 and still qualify if you’re otherwise healthy. Centers like UCLA don’t set an upper age limit - they look at your heart, your lungs, your strength, and your support system. The real question isn’t how old you are. It’s whether your body can handle the stress of surgery and recovery.

Obesity is a big hurdle. If your BMI is over 45, most centers won’t proceed. Some, like Vanderbilt, won’t even consider you if your BMI is above 35 without weight loss first. Why? Because extra weight makes surgery riskier. It raises the chance of infection, poor healing, and even kidney failure after transplant. Studies show obese patients have a 35% higher risk of surgical complications and a 20% higher chance of losing the new kidney.

Your heart and lungs matter just as much as your kidneys. If you have severe pulmonary hypertension - pressure in your lung arteries above 70 mm Hg - you’re not a candidate. Same goes for long-term oxygen dependence. Your heart needs to pump well too. Ejection fraction below 35%? That’s usually a stop sign. You’ll need cardiac tests - echocardiograms, stress tests, sometimes a heart catheter - before they’ll even put you on the list.

What Disqualifies You?

Some things are absolute deal-breakers. No exceptions.

Active cancer. If you’re currently being treated for cancer, or if your cancer is likely to come back after transplant, you’re not eligible. Most centers require you to be cancer-free for at least two years before considering you - longer for aggressive cancers like melanoma or lung cancer.

Untreated infections. HIV isn’t automatic disqualification anymore, but only if your viral load is undetectable and your CD4 count is above 200. Same with hepatitis B - if the virus is active in your blood, you’re out. You need to be clean of active infections like tuberculosis or endocarditis before surgery.

Drug or alcohol abuse. If you’re still using street drugs or drinking heavily, you won’t get a transplant. It’s not about judgment - it’s about survival. Immunosuppressants are dangerous if you miss doses or mix them with alcohol. You’ll need to prove you’ve been clean for at least six months, often with counseling and random testing.

Severe mental illness without support? Also a no. If you’re unable to manage your own meds, attend appointments, or understand the risks, transplant centers won’t risk giving you a kidney. That’s why every center checks your mental health, your support system, and your ability to follow through. They don’t just want to save your life - they want to make sure it lasts.

The Evaluation Process

Getting on the list isn’t a quick phone call. It’s a months-long process.

You’ll start with blood tests - to check your immune system, blood type, and tissue match. Then you’ll get screened for viruses like HIV, hepatitis, and CMV. A chest X-ray and EKG look at your heart and lungs. Cancer screening includes colonoscopies, mammograms, skin checks - whatever’s age-appropriate.

But the most overlooked part? Your social and emotional readiness. Penn Medicine and Vanderbilt both use frailty tests. They check your grip strength, how fast you walk, whether you’ve lost weight without trying, and if you feel exhausted most days. If you’re frail, your chances of surviving surgery drop. They’ll also ask: Who drives you to appointments? Who reminds you to take your pills? Who calls the doctor if something’s wrong?

Most centers require a care partner. Someone who’s in it for the long haul. Not just family - someone reliable. If you live alone and have no one, you’ll be asked to find someone before they’ll list you. It’s not cruel. It’s practical. You’ll need help for months, maybe years.

The Surgery

The operation itself takes about three to four hours. You’re under full anesthesia. The surgeon places the new kidney in your lower belly - usually on the right or left side. The blood vessels of the new kidney are stitched to your own arteries and veins. The ureter - the tube that carries urine - is connected to your bladder.

Here’s something people don’t expect: your old kidneys usually stay in. Unless they’re infected, causing high blood pressure, or bleeding, they’re left alone. The new kidney doesn’t need them out of the way.

When blood starts flowing into the new kidney, you might see it make urine right away. That’s a good sign. But sometimes, it takes days. About 20% of deceased donor kidneys don’t start working immediately. That’s called delayed graft function. You’ll need dialysis for a few days until it kicks in. It’s not failure. It’s normal.

Recovery in the hospital takes about three to five days. You’ll be up walking the next day. Pain is managed, but you’ll feel sore. You’ll be on antibiotics and antivirals to prevent infection. And you’ll start immunosuppressants - right away.

Life After the Transplant

This is where most people fail. Not because the surgery didn’t work. But because they stop taking their pills.

You’ll need lifelong immunosuppressants. That means drugs that stop your immune system from attacking the new kidney. The standard combo? A calcineurin inhibitor like tacrolimus, an antiproliferative like mycophenolate, and a steroid like prednisone. Some centers add a monoclonal antibody at the start to prevent early rejection.

These drugs aren’t optional. Miss one dose, and your body might start rejecting the kidney. Rejection can happen anytime - even years later. That’s why you’ll see your transplant team often. Weekly for the first month. Then monthly for six months. Then every three months. Forever.

You’ll also need regular blood tests. To check your kidney function. To make sure your drug levels are right. Too little - risk of rejection. Too much - risk of infection, cancer, or kidney damage. It’s a tightrope.

Side effects are real. Weight gain. High blood pressure. Diabetes. Bone thinning. Higher risk of skin cancer. You’ll need to watch your diet, exercise, and sun exposure. No more tanning beds. No more skipping sunscreen.

But here’s the upside: your quality of life skyrockets. Most people go back to work. Travel. Play with their grandkids. Sleep through the night. No more dialysis machines. No more fluid limits. No more endless fatigue.

Success Rates and New Hope

The numbers are good. For living donor transplants, 97% of kidneys are still working after one year. For deceased donors, it’s 93%. After five years, 85% of living donor kidneys are still going strong. Deceased donor kidneys? Around 78%.

There’s new hope on the horizon. The Kidney Donor Profile Index (KDPI) helps match kidneys better. A high-KDPI kidney - from an older donor or someone with health issues - used to be seen as a last resort. Now we know: even those kidneys give people years of better life than dialysis. They’re not perfect, but they’re better than nothing.

Researchers are working on tolerance protocols. The dream? Teach the immune system to accept the new kidney without lifelong drugs. Early trials at Stanford and the University of Minnesota are showing promise. In five to ten years, we might see patients off immunosuppressants entirely.

Living donation is still the gold standard. One healthy person can give a kidney and live a full, normal life. It’s not risky - the donor’s remaining kidney grows to compensate. And the recipient gets a better-functioning kidney faster.

What If It Fails?

Sometimes, the kidney doesn’t last. Rejection, infection, or scarring can cause it to fail. If that happens, you go back to dialysis. And you can be listed again for another transplant.

Many people get a second - even a third - transplant. Success rates drop a little with each one, but they’re still better than staying on dialysis. The key? Stay healthy. Stay on your meds. Stay in touch with your team.

Next Steps

If you’re considering a transplant, start by talking to your nephrologist. Ask for a referral to a transplant center. Don’t wait until you’re on dialysis. The earlier you’re evaluated, the better your chances of getting a living donor and avoiding long waits.

If you’re healthy enough, consider becoming a living donor. One kidney can give someone back their life. And you’ll live just fine with one.

Transplant isn’t the end of the journey. It’s the beginning of a new one - with rules, risks, and responsibilities. But for most, it’s worth it. You get your life back. And that’s more than medicine can usually promise.