The Step-by-Step Guide to Kidney Transplantation

An overview of the kidney transplantation process

James Curley, collections specialist for the National Museum of Health and Medicine's (NMHM) Historical Collections, shows participants at NMHM's August Organ of the Month Club program a papier-mâché model of a kidney. Military Health; Creative Commons Attribution 4.0 International Public License

No treatment option for kidney failure comes remotely close to kidney transplantation in terms of superiority of health outcomes and quality of life. Patients who get a transplant often report that they feel like they "got their life back". The high phosphorus or potassium levels that they were used to seeing during their dialysis days become a thing of the past, blood pressure suddenly becomes so much easier to control, and often, the best part for a lot of patients is that they don't have to subject themselves to the strict dietary restrictions that are imposed on patients on dialysis.

All of this points to but one simple fact. No matter how much dialysis technology progresses, no matter how many hours of dialysis we realistically prescribe to our patients, dialysis any day is a poor copy of the kidney's function. Man hasn't yet made a dialysis machine that can outdo what nature's fantastic creation is capable of. 

So why does not every patient with kidney failure get a transplant? Here is why.


And the demand far outstrips the supply. At the end of 2009, more than 871,000 people were noted to have kidney failure in the US alone! Contrast that with the number of kidney transplants that are performed every year in the US (around 18,000) and you get an idea of the huge gap that exists. As of my writing this piece, 119,086 candidates were waiting for a kidney transplant.

As a patient, you might not be able to fight the barriers to a quick transplant. However, being knowledgeable about the process will at least let you be proactive about the process, and potentially give you precious wait time on the waiting list.

And when it comes to kidney transplantation, wait time earns you points. The more points you have (there are other factors that earn you points besides how long you have been wait listed, though) the earlier you are likely to get a kidney. Unlike, liver transplantation where your place on the wait list is decided based on how sick you are, that is (unfortunately) not the case with kidney transplantation.

This however might change in the future with new rules for kidney allocation having taken effect in Dec 2014.

In my experience as a nephrologist, I have often seen patients either ignorant or intimidated about the kidney transplantation process. I will try to break this process down in to more understandable steps:


Your kidney doctor will make the determination if you are a kidney transplant candidate according to standard guidelines. Not every patient with advanced kidney disease will be a candidate. The kidney doc will also let you know at what cut-off GFR can you be referred to a kidney transplant center. For most centers, this is a GFR at or below 30.  In other words, you don't have to be on dialysis to be considered eligible for transplantation. 


If you are considered a reasonable candidate by your nephrologist and you do receive a referral, you will often be sent to a nearby transplant center for further evaluation.

Geographical proximity and convenience is usually a factor in this choice.

The transplant center will walk you through the transplant evaluation process and the first visit can stretch to an entire day. They will then order a thorough work up and testing of your vital organs including the heart, blood vessels, brain, and lungs (click here for details). Age appropriate cancer screening will also be done. They will also try and determine if there could be psycho-social barriers to transplantation (eg. a history of non-compliance with a physician's directions/prescriptions, not keeping appointments, etc). 


After a transplant, you will be required to take anti-rejection medications indefinitely. Unfortunately, at this time, Medicare provides coverage for these medications only for 36 months. It is a policy of paralyzing stupidity when you realize that even though these drugs could cost up to $17,000 a year, not paying for this coverage and putting the patient back on dialysis (by not maintaining the transplanted kidney's function) costs Medicare $71,000 a year! Again, the law might change, but for now you will have to be cognizant of the fact that after three years of the transplant, you will need to be able to come up with a way to pay for these (often expensive) medications. Hence, financial evaluation is done by transplant centers to make sure you would able to bear the costs of anti-rejection medications. The idea behind the thorough evaluation is that the transplant center wants to make sure that you will make a fair candidate from the physical, psychological, social, and economic perspective.

If you are considered eligible, you will also be asked if you have a living donor who might be willing to donate to you. If yes, he or she will be evaluated as well to see if they are a good match. Here are the details for what's expected of a donor. Should you not have a donor but are otherwise eligible, you will be put on the waiting list. 


Once you are active on the list, you should expect to wait anywhere between a few months to 6 years to get a suitable match. The wait times will vary for each blood group, and will also vary by center and geographical location. For instance, as of 2003-2004, blood group AB had the shortest wait-listed median time of 853 days, while patients with blood group B could expect to wait about 1935 days (or over 5 years). Similarly, transplant times could vary by state (California candidates will often wait the longest).

I want to emphasize a few points here though. 

  • If you are on the list, but too sick to undergo the procedure for any reason (recent treatment for cancer, active infection, etc), you might be temporarily switched over to an "inactive" status. You will still be on the list though, and this time will still earn you points.
  • Patients can get listed at multiple transplant centers. However, when it comes to the time for transplantation, your geographical location and your ability to reach the center in time will influence whether you get the kidney or not
  • An important point that patients need to understand is that the wait list is not static. There is nobody who is a number 1 on the list, or number 9 on the list! Your position on the list is determined by the kidney as it becomes available. Once a kidney becomes available, a "virtual match" is run based on knowledge of your blood type and HLA type. Based on this, if you are the only match among the transplant center's pool of listed candidates, you could well be "number 1" on the list and be offered the kidney. If there are multiple potential candidates, other factors and algorithms come in to play and determine your position. Once a list is drawn, a final tissue cross match (this is a real test, as opposed to the computer run "virtual matching") is run to make sure that you will not reject the kidney outright once it is transplanted in to you.  


If you make it through the first four steps, you can expect a call from the transplant center asking you to rush to the hospital (even if it is at 2:00 am!). Your cross match results will be confirmed, and if negative, you will receive the kidney. Depending on the quality of the organ received, the kidney could start making urine right there on the operating table once it is transplanted in to you. Your hospital stay after that could be as short as 3-7 days.


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