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

When your kidneys fail, life changes overnight. Dialysis keeps you alive, but it’s exhausting, time-consuming, and doesn’t restore your quality of life like a transplant can. A kidney transplant isn’t just another surgery-it’s a second chance. But not everyone qualifies, and even if you do, the journey doesn’t end when you wake up from anesthesia. This is what you need to know about who can get a transplant, what happens during surgery, and how to stay healthy for years after.

Who Can Get a Kidney Transplant?

You don’t automatically qualify just because you have kidney failure. Transplant centers don’t just look at your GFR-they look at your whole body. To even be considered, most centers require a glomerular filtration rate (GFR) of 20 mL/min or lower. Some, like Mayo Clinic, will consider patients with a GFR up to 25 mL/min if their kidneys are crashing fast-losing 10 mL/min or more each year-or if they have a living donor ready. If you’re still on dialysis, you’re likely eligible. If you’re not on dialysis yet but your kidneys are failing, you might still be a candidate.

Age isn’t a hard barrier. Vanderbilt doesn’t set a cutoff, but they do watch older patients closely. At 75 or older, your chances drop-not because of age alone, but because of other health problems that come with it. UCLA doesn’t rule anyone out by age. They check your heart, lungs, strength, and mental clarity instead. If you’re 80 but active, alert, and have good support, you could still get a transplant.

Obesity is a big hurdle. A BMI over 45 will disqualify you at most centers. At Vanderbilt, a BMI of 35 or higher is a warning sign. Why? Fat increases surgical risk. A 2022 study in the American Journal of Transplantation found obese patients have a 35% higher chance of complications and a 20% higher risk of graft failure. If you’re overweight, you’ll need to lose weight before surgery-not just for the operation, but to give your new kidney the best shot.

Heart and lung health matter just as much as kidney function. If your right ventricle pressure is above 50 mm Hg (Mayo Clinic) or your pulmonary artery pressure hits 70 mm Hg (Vanderbilt), you’re out. Oxygen dependence? That’s a hard no. You need to breathe on your own. Your heart needs to pump well too. Most centers want an ejection fraction above 35-40%. If you’ve had a heart attack or severe blockages, you’ll need treatment first.

What Stops You From Getting a Transplant?

Some things are absolute deal-breakers. If you have active cancer, you can’t get a transplant. Not even if it’s "in remission." You need to wait-usually two to five years, depending on the cancer type. Melanoma? Five years. Colon cancer? Three. The fear isn’t just recurrence-it’s that immunosuppressants will let cancer grow unchecked.

Active infections? No. Untreated HIV with a CD4 count under 200 or a detectable viral load? No. Hepatitis B with active virus? Also no. You must be infection-free before surgery. Even a simple skin infection can delay things.

Substance abuse is a hard stop. If you’re using alcohol, opioids, or street drugs regularly, transplant centers won’t touch you. They need you to take pills every single day, for life. If you can’t do that now, you can’t be trusted to do it after. Some centers will let you back in after six months of clean testing and counseling-but only if you prove you’re serious.

Mental health matters too. Severe untreated depression, psychosis, or dementia? Those are red flags. You need to understand what’s happening, remember your meds, show up for appointments, and tell your team when something’s wrong. If you can’t do that, the transplant won’t work.

And you need someone to help you. Nebraska Medicine requires a care partner. Someone who drives you to appointments, watches your meds, calls the clinic if you’re sick, and sits with you during tough days. No one should go through this alone.

What Happens During the Surgery?

The surgery itself takes three to four hours. You’re under general anesthesia. The surgeon makes a cut in your lower belly, not your back. The new kidney goes in on one side-usually the right or left lower abdomen. Your own kidneys? They stay. Unless they’re causing infections, high blood pressure, or pain, there’s no reason to remove them.

The donor kidney’s artery and vein are connected to your pelvic blood vessels. The ureter-the tube that carries urine-is stitched to your bladder. Then, blood flow starts. In many cases, the new kidney starts making urine right away. That’s a good sign. 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. It’s not failure-it’s just slow to wake up.

Living donor transplants tend to work better. Why? The kidney is removed from a healthy person, cooled for only minutes, and implanted right away. Deceased donor kidneys can sit in cold storage for 24 hours or more. The longer it’s cold, the more stress it takes. That’s why living donor transplants have a 97% one-year survival rate, compared to 93% for deceased donors.

What Happens After Surgery?

You’re not out of the woods. The first month is intense. You’ll be in the hospital for three to seven days. Then you’ll come in weekly for blood tests. Your team checks your creatinine, electrolytes, and drug levels. They’re watching for rejection, infection, and side effects.

You’ll take three or more immunosuppressants every day, for life. Most people get a combo: tacrolimus (or cyclosporine) to block immune cells, mycophenolate (or azathioprine) to stop cell growth, and prednisone to calm inflammation. Some get extra drugs at first-antibodies like basiliximab-to prevent early rejection. These drugs save the kidney… but they also weaken your body’s defenses.

You’ll get infections more easily. A cold could turn into pneumonia. A cut could get infected. You’ll need to avoid crowds, raw meat, undercooked eggs, and gardening without gloves. You’ll need vaccines-but not live ones. Flu shots? Yes. Shingles vaccine? Only if you’re stable. Always check with your transplant team.

Side effects are real. Tacrolimus can hurt your kidneys, raise blood pressure, and cause tremors. Mycophenolate causes nausea and diarrhea. Prednisone leads to weight gain, mood swings, and bone loss. You’ll need calcium, vitamin D, and maybe a bone density scan. You’ll also need blood pressure meds, cholesterol drugs, and diabetes checks. Your new kidney can’t handle the same damage your old one did.

How Long Does a Transplanted Kidney Last?

Most transplants last a long time. One-year survival? 95% for living donor kidneys, 92% for deceased. Five-year survival? 85% for living, 78% for deceased. That’s better than dialysis. The 5-year survival rate for dialysis patients is only about 50%.

But transplants aren’t permanent. The biggest threat is chronic rejection-slow damage from immune attacks over time. It’s hard to detect until the kidney’s already weakened. That’s why you need annual checkups forever. Blood tests, ultrasounds, and sometimes biopsies. The Kidney Donor Profile Index (KDPI) helps match kidneys better. A high-KDPI kidney (from an older donor or someone with high blood pressure) still beats dialysis. A 2022 study showed these kidneys improve life expectancy by years, even if they don’t last as long.

Living donor kidneys last longer because they’re healthier going in. The National Kidney Registry reports 97% one-year survival for living donor transplants. That’s why many patients choose to wait for a living donor-even if it takes years.

What’s Next for Kidney Transplants?

Research is moving fast. Scientists are testing ways to train the immune system to accept the new kidney without lifelong drugs. Clinical trials at Stanford and the University of Minnesota are testing tolerance protocols. Some patients have already gone off all immunosuppressants-with no rejection. It’s early, but it’s real.

Organ preservation is improving too. New machines that keep kidneys alive and beating outside the body are being tested. That could mean fewer damaged kidneys and better outcomes.

And more people are getting transplants. In 2023, over 27,000 kidney transplants were done in the U.S. But there are still over 100,000 people waiting. The gap is huge. That’s why living donation matters more than ever. A healthy person can give one kidney and live normally. If you’re thinking about it, talk to your doctor. You might be the reason someone lives longer.