The kidneys filter and remove excess waste, minerals and fluid from the blood by producing urine. When the kidneys lose this filtering ability, harmful levels of fluid and waste accumulate in the body, which can raise the blood pressure and result in kidney failure (end-stage renal disease, which is also known as end-stage kidney disease). End-stage renal disease occurs when the kidneys have lost about 90 percent of their ability to function normally.

Common causes of end-stage renal disease include:

  • Diabetes
  • Chronic, uncontrolled high blood pressure
  • Chronic glomerulonephritis — an inflammation and eventual scarring of the tiny filters within your kidneys (glomeruli)
  • Polycystic kidney disease

People with end-stage renal disease need to have waste removed from their bloodstream via a machine (dialysis) or a kidney transplant to stay alive. A kidney transplant is a surgical procedure in which a healthy kidney from a live or deceased donor is placed into a person whose kidneys no longer function properly. It is often the treatment of choice for kidney failure compared to a lifetime on dialysis.

Benefits of kidney transplant compared to dialysis:

  • Better quality of life
  • Lower risk of death
  • Fewer dietary restrictions
  • Lower treatment cost

Some people may also benefit from receiving a kidney transplant before needing to go on dialysis, a procedure known as preemptive kidney transplant.

Contraindications for kidney transplant:

For certain people with kidney failure, a kidney transplant may be more risky than dialysis. Conditions that may prevent an individual from being eligible for a kidney transplant include:

  • Advanced age
  • Severe heart disease
  • Active or recently treated cancer
  • Poorly controlled mental illness
  • Dementia
  • Alcohol or drug abuse
  • Any other factor that could affect the patient’s ability to safely undergo the procedure and take the medications needed to prevent organ rejection

Screening for eligibility for kidney transplant:

Before the kidney transplant can be considered in a patient with ESRD, the following factors need to be considered:

  • Are healthy enough to have surgery and tolerate lifelong post-transplant medications
  • Have any medical conditions that would interfere with transplant success
  • Are willing and able to take medications as directed and follow the suggestions of the transplant team

The evaluation process may take several days and includes:

  • A thorough physical exam
  • Imaging scans, such as X-ray, MRI or CT scans
  • Blood tests
  • Psychological evaluation
  • Any other necessary testing as determined by your doctor

Tests to determine whether a donated kidney may be suitable for you include:

  • Blood typing.It’s preferable to get a kidney from a donor whose blood type matches or is compatible to your own. Blood-type incompatible transplants are also possible but require additional medical treatment before and after transplant to reduce the risk of organ rejection. These are known as ABO incompatible kidney transplants.
  • Tissue typing.If your blood type is compatible, the next step is a tissue typing test called human leukocyte antigen (HLA) typing. This test compares genetic markers that increase the likelihood the transplanted kidney will last a long time. A good match means it’s less likely that your body will reject the organ.
  • The third and final matching test involves mixing a small sample of your blood with the donor’s blood in the lab. The test determines whether antibodies in your blood will react against specific antigens in the donor’s blood. A negative crossmatch means they are compatible and your body isn’t as likely to reject the donor kidney. Positive crossmatch kidney transplants are also possible but require additional medical treatment before and after the transplant to reduce the risk of your antibodies reacting to the donor organ.

Additional factors your transplant team may consider in finding the most appropriate donor kidney for you include matching age, kidney size and infection exposure.

Types of kidney transplant

There are three types of kidney transplant:

  1. Deceased donor kidney transplant
  2. Living-donor kidney transplant
  3. Pre-emptive kidney transplant

  1. Deceased donor kidney transplant

A deceased-donor kidney transplant is when a kidney from someone who has recently died is removed with consent of the family or from a donor card and placed in a recipient whose kidneys have failed and no longer function properly and is in need of kidney transplantation. If a compatible living donor isn’t available for a kidney transplant, the patient’s name will be placed on a kidney transplant waiting list to receive a kidney from a deceased donor. Some patients get a match within several months, and others may wait several years. While on the list, you will have periodic health checkups to ensure that you are still a suitable candidate for transplantation.

The donated kidney is either stored on ice or connected to a machine that provides oxygen and nutrients until the kidney is transplanted into the recipient. The donor and recipient are often in the same geographic region as the transplant center to minimize the time the kidney is outside a human body. Only one donated kidney is needed to sustain the body’s needs. For this reason, a living person can donate a kidney, and living-donor kidney transplant is an alternative to deceased-donor kidney transplant.

  1. Living-donor kidney transplant

Finding a willing living kidney donor is an alternative to waiting for a compatible deceased-donor kidney to become available.

Family members are often the most likely to be compatible living kidney donors. But successful living-donor transplants are also common with kidneys donated from unrelated people, such as friends, co-workers or religious congregation members.

Paired donation is another type of living kidney donation if you have a willing kidney donor whose organ is not compatible with you or does not match well for other reasons. Rather than donating a kidney directly to you, your donor may give a kidney to someone who may be a better match. Then you receive a compatible kidney from that recipient’s donor.

In some cases, more than two pairs of donors and recipients may be linked with a non-directed living kidney donor to form a donation chain with several recipients benefitting from the non-directed donor’s gift.

If a compatible living donor isn’t available, your name will be placed on a waiting list for a deceased-donor kidney. Because there are fewer available kidneys than there are people waiting for a transplant, the waiting list continues to grow. The waiting time for a deceased-donor kidney is usually a few years.

Compared with deceased-donor kidney transplant, living-donor kidney transplant offers these benefits:

  • Less time spent on a waiting list, which could prevent possible complications and deterioration of health
  • Potential avoidance of dialysis if it has not been initiated
  • Better short- and long-term survival rates
  • A pre-scheduled transplant once your donor is approved versus an unscheduled, emergency transplant procedure with a deceased donor
  • Living-donor kidneys almost always start working immediately after transplant compared with deceased-donor kidneys that can have delayed function
  1. Pre-emptive kidney transplant

A pre-emptive kidney transplant is a kidney transplant that takes place before your kidney function deteriorates to the point of needing dialysis to replace the normal filtering function of the kidneys.

Currently, most kidney transplants are performed on people who are on dialysis because their kidneys are no longer able to adequately clean impurities from the blood.

Pre-emptive kidney transplant is considered the preferred treatment for end-stage kidney disease, but only about 20 percent of kidney transplants are performed pre-emptively in the U.S.

Several factors have been linked to the lower than expected rate of pre-emptive kidney transplants, such as:

  • Shortage of donor kidneys
  • Lack of access to transplant centers
  • Low rates of physician referrals for the procedure among candidates of lower socio-economic status
  • Lack of physician awareness of current guidelines

The benefits of pre-emptive kidney transplant before dialysis for people with end-stage kidney disease include:

  • Lower risk of rejection of the donor kidney
  • Improved survival rates
  • Improved quality of life
  • Lower treatment costs
  • Avoidance of dialysis and its related dietary restrictions and health complications

These benefits of pre-emptive kidney transplant are especially significant among children and adolescents with end-stage kidney disease.

Risks of pre-emptive kidney transplant include early exposure to the risks associated with surgery and potentially wasting native kidney function.

When a compatible deceased-donor kidney becomes available, you will be notified by your transplant center. You must be ready to go to the center immediately for final transplant evaluation.

If the results of the final transplant evaluation are satisfactory, the kidney transplant surgery can proceed immediately.

Kidney transplants are performed with general anesthesia, so you’re not aware during the procedure. The surgical team monitors your heart rate, blood pressure and blood oxygen level throughout the procedure.

During the surgery:

  • The surgeon makes an incision and places the new kidney in your lower abdomen. Unless your own kidneys are causing complications such as high blood pressure, kidney stones, pain or infection, they are left in place.
  • The blood vessels of the new kidney are attached to blood vessels in the lower part of your abdomen, just above one of your legs.

The new kidney’s ureter — the tube that links the kidney to the bladder — is connected to your bladder.

Living-donor organ donation chain

Risks of living-donor kidney transplant are similar to those of deceased-donor kidney transplant. They include risks associated with the surgery, organ rejection and side effects of anti-rejection medications.

After the surgery:

After your kidney transplant, you can expect to:

  • Spend several days to a week in the hospital.Doctors and nurses monitor your condition in the hospital’s transplant recovery area to watch for signs of complications. Your new kidney will make urine like your own kidneys did when they were healthy. Often this starts immediately. In other cases it may take several days. Expect soreness or pain around the incision site while you’re healing. Most kidney transplant recipients can return to work and other normal activities within three to eight weeks after transplant. No lifting objects weighing more than 10 pounds or exercise other than walking until the wound has healed (usually about six weeks after surgery).
  • Have frequent checkups as you continue recovering.After you leave the hospital, close monitoring is necessary for a few weeks. You may need blood tests several times a week and have your medications adjusted in the weeks following your transplant. During this time, if you live in another town, you may need to make arrangements to stay near the transplant center.
  • Take medications the rest of your life.You’ll take a number of medications after your kidney transplant. Drugs called immunosuppressants (anti-rejection medications) help keep your immune system from attacking and rejecting your new kidney. Additional drugs help reduce the risk of other complications, such as infection, after your transplant.
  • Deceased-donor kidney transplant
  • A deceased-donor kidney transplant is when a kidney from someone who has recently died is removed with consent of the family or from a donor card and placed in a recipient whose kidneys have failed and no longer function properly and is in need of kidney transplantation.
  • The donated kidney is either stored on ice or connected to a machine that provides oxygen and nutrients until the kidney is transplanted into the recipient. The donor and recipient are often in the same geographic region as the transplant center to minimize the time the kidney is outside a human body.

Complications of the procedure

Kidney transplant surgery carries a risk of significant complications, including:

  • Blood clots
  • Bleeding
  • Leaking from or blockage of the tube (ureter) that links the kidney to the bladder
  • Infection
  • Failure of the donated kidney
  • Rejection of the donated kidney
  • An infection or cancer that can be transmitted with the donated kidney
  • Death, heart attack and stroke

The long term success of a kidney transplant depends on many things. You should:

  • Be seen by your transplant team on a regular basis and follow their advice
  • Take your anti-rejection medications daily in the proper dose and at the right times, as directed by the transplant team, to keep your body from rejecting your new kidney.
  • Follow the recommended schedule for lab tests and clinic visits to make sure that your kidney is working properly.
  • Follow a healthy lifestyle including proper diet, exercise, and weight loss if needed

Rejection and Transplant Medicine

What is rejection?

Rejection is the most common and important complication that may occur after receiving a transplant. Since you were not born with your transplanted kidney, your body will think this new tissue is “foreign” and will try to protect you by “attacking” it. Rejection is a normal response from your body after any transplant surgery. You must take anti-rejection medicine exactly as prescribed to prevent rejection.

Are there different types of rejection?

There are two common types of rejection:

  • Acute Rejection – Usually occurs anytime during the first year after transplant and can usually be treated successfully.
  • Chronic Rejection – Usually occurs slowly over a long period of time. The causes are not well understood and treatment is often not successful.

What are anti-rejection medications?

Anti–rejection (immunosuppressant) medications decrease the body’s natural immune response to a “foreign” substance (your transplanted kidney). They lower (suppress) your immune system and prevent your body from rejecting your new kidney.

Why do I need to take anti-rejection medication?

Kidney rejection is hard to diagnose in its early stages. Rejection is often not reversible once it starts. You should never stop taking your anti-rejection medication no matter how good you feel and even if you think your transplanted kidney is working well. Stopping or missing them may cause a rejection to occur.

How should I take anti-rejection medication?

Here are some tips to help you take your anti-rejection (immunosuppressant) medication as directed:

  • Make taking your medicine part of your daily routine
  • Use digital alarms and alerts to remember when to take your medication. Be creative because it is easy to forget, especially once you are feeling wellKnow all of your medications by name and dose. Know the reason for taking each medication. Click here for form.
  • Ask for and review all written instructions for any change in medication dose or frequency
  • Tell your transplant team of problems and concerns about medications during every clinic visit
  • If a doctor other than a member or your transplant team gives you a prescription, notify the transplant team before taking. Certain medications can interfere with your anti-rejection medications and keep them from working.
  • Continue to take your anti-rejection medication no matter how great you feel, even if you think your transplanted kidney is working well. Stopping them may cause rejection to occur.
  • What are the side-effects of anti-rejection medications?
  • Some of the most common side-effects of anti-rejection (immunosuppressant) medications include high blood pressure, and weight gain, an increased chance of having infections, and increased risk of some forms of cancer.

Infection

Why is infection a concern after kidney transplant?

The anti-rejection medicines that help keep your body from rejecting your transplanted kidney also lower your immune system. Because your immune system is lowered, viral and other infections can be a problem.

What is the best way to stay healthy? 

Finding and treating infections as early as possible is the best way to keep you and your transplanted kidney healthy. Exposure to diseases such as the flu or pneumonia can make you very sick. Receiving vaccines as determined by your transplant team can help you stay healthy. It is also important to frequently wash your hands or use an antimicrobial gel during cold and flu season.

What problems should I report to my doctor?

You should report any of the following problems to your doctor as soon as possible:

  • Sores, wounds, or injuries; especially those that don’t heal
  • Urinary tract infection symptoms such as frequent urge to urinate, pain or burning feeling when urinating, cloudy or reddish urine, or bad smelling urine
  • Respiratory infection symptoms such as cough, nasal congestion, runny nose, sore or scratchy throat, or fever

How can I avoid getting infections?

To avoid getting infections you should:

  • Wash your hands regularly
  • Maintain good hygiene habits especially around pets
  • Avoid close contact with people who have contagious illnesses
  • Avoid close contact with children recently vaccinated with live vaccines (see section on Vaccines). Also, no one in the household should get the nasal influenza vaccine
  • Practice safe food handling. For more information on safe food handling go to USDA: Basics for Handling Food Safely
  • Inform your doctor well in advance of any travel plans