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

When your kidneys fail, life changes in ways you can’t ignore. Dialysis keeps you alive, but it doesn’t give you back your life. A kidney transplant offers something else: freedom from needles, strict schedules, and constant fatigue. For many, it’s the best shot at returning to normal-working, traveling, playing with grandkids, sleeping through the night. But it’s not simple. It’s not automatic. And it doesn’t end when the surgery is over.

Who Qualifies for a Kidney Transplant?

You don’t just sign up for a transplant because you have kidney disease. You need to be in the right condition to survive the surgery and thrive afterward. Most transplant centers require you to have end-stage renal disease (ESRD), meaning your kidneys are working at 15% or less of normal capacity. That’s measured by your glomerular filtration rate (GFR), and if it’s below 20 mL/min, you’re typically eligible. Some centers, like Mayo Clinic, may consider you even if your GFR is up to 25 mL/min-if your kidney function is dropping fast or you already have a living donor lined up.

Age isn’t a hard cutoff. You can be 70, 80, even older-and still qualify-if you’re otherwise healthy. Vanderbilt and UCLA look at your whole picture: heart health, muscle strength, mental clarity, not just your birth year. But if you’re frail, weak, or have other serious conditions, the risks may outweigh the benefits.

Obesity is a major barrier. A BMI over 35 raises your risk of complications. Over 45? Most centers won’t operate. Why? Fat makes surgery harder, increases infection risk, and lowers the chance the new kidney will last. Studies show obese patients have a 35% higher chance of surgical problems and a 20% higher risk of graft failure.

Your heart and lungs matter too. If you have severe pulmonary hypertension-pressure in your lung arteries above 70 mm Hg-you won’t qualify. Same if you’re on oxygen long-term because of COPD. Your heart needs to be strong enough to handle the stress. An echocardiogram will check your ejection fraction. If it’s below 35%, you’re usually ruled out.

Then there’s the mental and social side. Can you remember to take 10 pills every day for the rest of your life? Do you have someone to drive you to appointments, help you if you feel sick, or notice if something’s wrong? Most centers require a care partner. If you’re struggling with untreated depression, active addiction, or can’t follow medical advice, you won’t be approved. Transplant centers aren’t being harsh-they’re being realistic. A failed transplant isn’t just a loss. It’s a setback that could cost you your life.

What Disqualifies You?

Some conditions are absolute no-go’s. No exceptions.

Active cancer-unless you’ve been cancer-free for years. For most cancers, you need at least 2-5 years of remission before you’re considered. Skin cancer? Maybe. Lung cancer? Probably not.

Untreated infections-like hepatitis B or C with active virus in your blood, or HIV with a CD4 count below 200. These don’t just make surgery dangerous-they can kill the new kidney.

Drug or alcohol abuse-if you’re still using, you’re not eligible. Not because they’re judging you, but because missing doses of anti-rejection drugs can lead to immediate, irreversible rejection. One missed week can mean losing the transplant.

Severe, uncontrolled mental illness-if you can’t manage your own care, you won’t be approved. This isn’t about stigma. It’s about survival. You need to understand what’s happening in your body and act on it.

Even if you’ve had cancer, an infection, or addiction in the past, you might still qualify-if you’ve been clean and stable for years. Transplant centers track your history closely. They want proof you’ve changed, not just promises.

What Happens During the Surgery?

The surgery itself takes about 3 to 4 hours. You’re under general anesthesia, so you won’t feel a thing. The surgeon places the new kidney in your lower abdomen-not where your old kidneys are. Your original kidneys are usually left in place unless they’re causing pain, infection, or high blood pressure.

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. In most cases, the kidney starts working right away. You’ll see urine flowing within minutes. But sometimes, especially with kidneys from deceased donors, it takes days to kick in. That’s called delayed graft function. About 1 in 5 transplants like this need temporary dialysis until the kidney wakes up.

Recovery starts fast. Most people are up and walking the next day. You’ll be in the hospital for 3 to 7 days. Pain is managed with medication. You’ll be on a strict diet and fluid plan. Your medical team will watch your urine output, blood pressure, and kidney function like hawks.

And here’s something most people don’t expect: you won’t feel like you’ve had major surgery. No chest incisions, no rib spreading. It’s a big operation, but the recovery is surprisingly smooth-for those who follow the rules.

Life After the Transplant: The Real Work Begins

The transplant isn’t the finish line. It’s the starting line.

You’ll take immunosuppressants every single day for the rest of your life. These drugs stop your body from attacking the new kidney. Common ones include tacrolimus, mycophenolate, and prednisone. Miss a dose? Risk rejection. Take too much? Risk infection, diabetes, or cancer. It’s a tightrope walk.

At first, you’ll see your transplant team every week. After a month, it’s every two weeks. Then monthly. After six months, you’ll come in every three months. And even then-you’ll need annual blood tests, ultrasounds, and biopsies if anything looks off.

Side effects are real. Weight gain. High blood sugar. High cholesterol. Tremors. Hair loss. Acne. These aren’t just annoyances-they can lead to heart disease, diabetes, or bone loss. Your doctor will adjust your meds, add new ones, and push you to eat better and move more.

And you must avoid infections. No crowded places in the first few months. No gardening without gloves. No pet litter duty. No raw sushi. Even a cold can turn dangerous. You’ll get flu shots, pneumonia shots, and maybe even hepatitis vaccines. Your immune system is turned down on purpose. That means germs you used to shrug off can now land you in the hospital.

How Long Does a Transplanted Kidney Last?

The numbers are encouraging. For living donor transplants, 95% of kidneys are still working after one year. After five years, 85% are still going strong. For deceased donor kidneys? 92% survive the first year. 78% make it to five.

Why the difference? Living donor kidneys are healthier. They’re removed from a living person, flushed with preservation fluid, and implanted quickly. Deceased donor kidneys sit in cold storage longer. They’ve been through trauma. That’s why living donation is the gold standard.

But even the best kidney won’t last forever. The average lifespan of a transplanted kidney is 10 to 15 years. Some last 20 or more. Others fail sooner. If it fails, you can go back on dialysis-and get on the waiting list again. Many people get a second transplant. Some get three.

Recent advances are helping. The Kidney Donor Profile Index (KDPI) helps match kidneys to recipients. A high-KDPI kidney-say, from an older donor or someone with high blood pressure-used to be considered a last resort. Now, we know even these kidneys can give you years of better life than dialysis. If you’re older or have been waiting a long time, a high-KDPI kidney might be your best option.

What’s New in Kidney Transplants?

Science is moving fast. Researchers are testing ways to reduce or even eliminate lifelong immunosuppression. At Stanford and the University of Minnesota, clinical trials are using cell therapies and tolerance-inducing protocols to teach the immune system to accept the new kidney without drugs. It’s early, but promising.

Organ preservation is improving too. New machines keep kidneys alive and functioning outside the body longer. That means better outcomes, especially for kidneys from distant donors.

And living donation? It’s growing. More people are stepping forward-not just family, but strangers. The National Kidney Registry helps match incompatible pairs: you give your kidney to someone else’s loved one, and your loved one gets a kidney from another donor. It’s a chain. And it saves lives.

What Should You Do Next?

If you’re thinking about a transplant, talk to your nephrologist. Ask for a referral to a transplant center. Don’t wait until you’re on dialysis. Get evaluated early. The process can take months. You’ll need blood tests, heart scans, mental health reviews, and social work assessments.

If you have a living donor, start the process now. Don’t assume they’re eligible. They’ll need the same tests you do. And if they’re not a match? Don’t give up. There are paired exchange programs that can find a solution.

And if you’re on dialysis? Don’t lose hope. Transplant isn’t just for the young. It’s for anyone who’s willing to do the work. The survival rate after transplant is twice that of dialysis. You’re not just getting a new kidney. You’re getting a new life.

What If You’re Not Eligible?

If you’re not approved now, don’t give up. Many people improve their eligibility over time. Lose weight. Quit smoking. Get your diabetes under control. Treat your depression. Get help with addiction. Follow your doctor’s advice. Reapply in 6 to 12 months. Transplant centers want you to succeed. They’ll help you get there-if you’re willing to try.

A kidney transplant isn’t a miracle. It’s a partnership-with your medical team, your body, and your own discipline. It’s not easy. But for thousands of people every year, it’s the best decision they ever made.