Kidney transplantation offers a vital and often life-changing treatment option for many patients facing chronic kidney disease. This complex process involves surgically implanting a healthy kidney from another person into a patient with kidney failure. While it can take years to receive a new kidney due to high demand and limited supply, a successful transplant can significantly improve a patient's quality of life and extend their life expectancy compared to dialysis.

Ensuring compatibility between donor and recipient is paramount, with extensive testing conducted to achieve the best possible match. Unless medically necessary, a patient's own kidneys typically remain in place. The operation usually takes three to five hours, followed by an average hospital stay of five to six days.

Who Benefits from a Transplant

Individuals with end-stage renal disease (ESRD) or poorly functioning kidneys are often candidates for a kidney transplant. Even those with advanced chronic kidney disease who are not yet on dialysis may be considered for a "preemptive" kidney transplantation. Recent data suggests that patients who receive transplants before starting dialysis often experience the best outcomes.

The benefits of a successful kidney transplant are substantial: a longer life expectancy, a relatively unrestricted diet, the ability to become pregnant and bear children, and a lifestyle free from dialysis constraints, allowing a return to work, school, and travel. Patients may even be able to train for athletic competition.

Kidneys suitable for transplant can come from various sources: deceased donors, living donors who are related to the recipient, living donors who are not related (such as a spouse, friend, coworker, or neighbor), and even altruistic donors who wish to help someone they don't know.

Transplant Candidate Criteria

Not everyone is a candidate for a kidney transplant. Individuals with active cancer (with specific waiting periods depending on cancer type), liver failure (unless a simultaneous liver transplant is planned), severe heart disease, or decreased blood flow to the legs (unless reversible) are typically not considered. Active mental illness that prevents informed consent or medication compliance also disqualifies a candidate.

Certain conditions must be treated prior to transplant, including active infections (like viral liver infections, diabetic foot infections, or tuberculosis), stomach ulcers, irreversible heart disease or decreased blood flow to legs, a predisposition to stroke, or substance abuse.
Regarding cancer, a person usually needs to be cancer-free for three to five years before receiving any transplant, though early-stage cancers might require only a two-year wait. This measure reduces the risk of cancer recurrence, as immunosuppressive medications can enable tumors to grow more aggressively. For liver cancer, a kidney transplant is generally not recommended unless a simultaneous liver transplant is planned. For blood cancers like multiple myeloma, kidney transplantation is usually not advised due to the increased risks posed by anti-rejection medications.

Starting the Transplant Process

Evaluation for a kidney transplant can begin when kidney function drops to 20% or less. Patients interested in evaluation should meet with a kidney transplant team, either through a referral from a nephrologist or dialysis center, or by self-referral. The transplant center will gather all medical records, including x-rays, ultrasounds, blood and urine reports, and insurance information, then schedule an appointment for a comprehensive transplant evaluation.

The candidate will undergo a complete health assessment, including questions about family and social history, to determine preparedness for surgery and transplant. While requirements vary by center, common studies include:

• Blood tests (for blood type, tissue type, GFR, viral testing like hepatitis C and HIV)

• Urine tests

• Complete physical exam

• EKG, X-ray

• Dental check-up (to rule out untreated infections)

• Ultrasound to assess kidney damage

• Colonoscopy

• Psycho-social evaluation (to check for compliance risk and mental health state)

All key members of the transplant team will meet with the candidate. For optimal transplant outcomes, the recipient and donor should ideally be blood-type compatible and non-reactive immunologically. Cross-matching determines if the recipient is sensitized to the potential donor's tissue; a 'negative' cross-match is desired, indicating no sensitization. Advances in immunosuppressive medications have improved outcomes even with fewer antigen matches, or even no matches at all (zero-antigen match). The transplant team then discusses all study results to determine if a kidney transplant is the best therapy for that individual.

Life After Transplant and Potential Risks

Once accepted into the program, the person is listed with the United Network for Organ Sharing (UNOS) database, which manages donor organ matching across the U.S. The average waiting time for a kidney is typically two to five years, though regional factors and blood type can influence this. Candidates may be called into the hospital multiple times for additional blood studies before receiving a transplant.

Other factors, such as the recipient’s current health and the quality of the donor-recipient match, are considered before a final decision is made. It's important to understand that delays can occur, and patients may be called in several times before a kidney is ultimately designated for them, which can be frustrating but is part of the process.

After a transplant, lifestyle adjustments are necessary. In addition to taking anti-rejection medicines and following medical guidelines, recipients should protect their new kidney from trauma, often meaning avoiding contact and other "rough" sports. It's also crucial to avoid people who are ill with contagious diseases and stay away from moldy, musty environments, as the immune system is compromised by anti-rejection medication, increasing the risk of infection and respiratory complications.
While kidney transplants offer immense benefits, they also carry risks common to any surgery, such as anesthesia complications, bleeding, blood vessel clotting, and infection. Specific risks for kidney transplants include:

• Clotting of the blood vessels to the new kidney, causing damage

• Blockage of urine flow

• Non-function of the kidney (either it never starts working or stops later)

• Rejection of the 'foreign' kidney by the recipient’s body

• Infection (due to decreased immune function from anti-rejection medication)

• Cancer, especially skin cancer (requiring vigilance and frequent professional skin checks)

Close monitoring before, during, and after transplantation helps to minimize the impact of these complications and improve overall outcomes.