When your kidneys fail, life changes fast. Dialysis keeps you alive, but it’s not a cure. It’s exhausting, time-consuming, and doesn’t let you live like you used to. For many people with end-stage renal disease (ESRD), a kidney transplant is the best path forward-not just to survive, but to truly live again. The numbers don’t lie: if you get a transplant, you’re about 35% more likely to be alive five years later than if you stay on dialysis. That’s not a small difference. That’s life versus a daily routine that steals your energy, your time, and your freedom.

Who Can Get a Kidney Transplant?

Not everyone with kidney failure qualifies. It’s not just about how bad your kidneys are-it’s about whether your whole body can handle the surgery and the lifelong treatment that comes after. Most transplant centers agree on one thing: you need to have ESRD. That means your kidneys are working at 15% or less of normal function, measured by a glomerular filtration rate (GFR) of 15 mL/min/1.73m² or lower. Some centers, like Mayo Clinic, may consider you even if your GFR is as high as 20-25 mL/min, especially if your kidney function is dropping fast or you have a living donor ready to go.

Age isn’t a hard stop. There’s no universal cutoff. While Vanderbilt University Medical Center says age 75 or older is a red flag, UCLA and others look at the whole picture. A healthy 80-year-old with strong bones, good heart function, and solid family support might be a better candidate than a 60-year-old with diabetes, heart disease, and no one to help them take pills every day.

Weight matters too. A BMI over 35 raises your risk of complications during surgery and after. Over 45? Most centers won’t even consider you until you lose weight. Why? Fat doesn’t just make surgery harder-it increases the chance of infection, delays healing, and raises the risk that the new kidney will fail. One study found that obese patients have a 20% higher chance of graft failure. Losing even 10-15% of body weight can get you on the list.

Your heart and lungs have to be strong enough to survive surgery. If you have severe pulmonary hypertension-meaning high pressure in the arteries leading to your lungs-you’re likely not a candidate. Mayo Clinic draws the line at a right ventricle systolic pressure (RVSP) over 50 mm Hg. Vanderbilt is stricter: anything above 70 mm Hg is an automatic disqualifier. If you need oxygen all the time because of COPD or another lung disease, that’s also a barrier. Your heart needs to pump well too. An ejection fraction below 35-40% usually means you need cardiac treatment first, maybe even a stent or bypass, before you can even think about a transplant.

What Disqualifies You?

Some things are absolute deal-breakers. You can’t get a transplant if you have:

• Active cancer-unless you’ve been cancer-free for a set number of years (usually 2-5, depending on the type). A tumor that could grow back under immunosuppression? Too risky.
• Untreated infections-like active tuberculosis, hepatitis B with high viral load, or HIV with CD4 count under 200. These can’t be controlled well enough after transplant.
• Severe mental illness-if you can’t manage your own care, take pills on time, or attend appointments, the transplant team won’t put you on the list. Depression or anxiety? Fine. If you’re refusing meds or can’t remember them? Not okay.
• Active drug or alcohol abuse-you need to be sober for at least six months before evaluation. Relapse after transplant? The new kidney won’t last.

The National Health Service in the UK puts it simply: you must be well enough to handle major surgery, and the transplant must have a good chance of working. That’s the bottom line.

The Surgery: What Happens?

The operation itself takes 3 to 4 hours. You’re under full anesthesia. The surgeon places the new kidney in your lower belly-not where your old kidneys are, but on the side, near your pelvis. The donor kidney’s blood vessels are connected to your artery and vein. The ureter (the tube that carries urine) is attached to your bladder. Your own kidneys? Usually left in place. Unless they’re causing infections, pain, or high blood pressure, there’s no reason to remove them.

The new kidney often starts making urine right away. But sometimes, especially with kidneys from deceased donors, it takes a few days to wake up. About 1 in 5 of these transplants need temporary dialysis after surgery. That doesn’t mean it failed. It just means the kidney needed time to adjust.

Living donor transplants are the gold standard. A kidney from a healthy living person-often a family member or friend-has better outcomes. The 1-year survival rate for living donor kidneys is 97%. For deceased donor kidneys? 93%. Why? Because living donor kidneys are healthier, better matched, and don’t spend time in cold storage before transplant. They’re also usually transplanted before the recipient even starts dialysis, which gives them a huge advantage.

Life After the Transplant: The Real Work Begins

Getting the kidney is only half the battle. The other half? Keeping it alive.

You’ll be on immunosuppressants for life. These drugs stop your immune system from attacking the new kidney. But they also lower your defenses against infections, cancer, and other illnesses. The standard combo? A calcineurin inhibitor (like tacrolimus), an antiproliferative drug (like mycophenolate), and a steroid (like prednisone). Some people get extra drugs at the start-induction therapy-to give the new kidney a smoother landing.

Side effects are real. You might gain weight, get high blood pressure, develop diabetes, or have shaky hands. Some people get acne or hair growth. These aren’t just inconveniences-they can lead to long-term problems if not managed. That’s why follow-up is non-negotiable.

Right after surgery, you’ll go in weekly. Then monthly for the next few months. After that? Every three months. And once a year, forever. Blood tests, urine checks, and sometimes biopsies to check for early signs of rejection. You’ll also get regular screenings for skin cancer, lymphoma, and other cancers that immunosuppressants increase your risk for.

One study found that 5-year graft survival is 85% for living donor transplants and 78% for deceased donor ones. That means 1 in 5 deceased donor kidneys fail within five years. But even then, many people live longer and better than they did on dialysis.

The Hidden Support System

You can’t do this alone. Nebraska Medicine requires every transplant patient to have a designated care partner-someone who drives you to appointments, reminds you to take pills, and calls the doctor if something feels off. That’s not optional. That’s survival.

Psychological health is just as important as physical health. If you’re depressed, anxious, or isolated, you’re more likely to miss doses. Miss doses? Rejection. Rejection? Loss of the kidney. Transplant centers now use frailty assessments to catch people who might struggle. They look at grip strength, walking speed, weight loss, and energy levels. If you’re too frail, they’ll help you build strength before surgery.

And yes-there’s still a waiting list. In the U.S., over 100,000 people are waiting for a kidney. The average wait is 3-5 years. But living donors change the game. If you have someone willing to donate, you can skip the list. That’s why public awareness matters. One donor can save a life-and free up a deceased donor kidney for someone else.

What’s Next? The Future of Transplants

New tools are changing the game. The Kidney Donor Profile Index (KDPI) helps match kidneys with the longest expected life to patients who need them most. A high-KDPI kidney might come from an older donor or someone with a history of high blood pressure. But even those kidneys give patients a better shot at life than staying on dialysis.

Researchers are working on ways to reduce or even eliminate lifelong immunosuppression. Clinical trials at Stanford and the University of Minnesota are testing tolerance-inducing therapies-training the immune system to accept the new kidney without drugs. If it works, it could change everything. Imagine a transplant where you don’t need daily pills. That’s not science fiction anymore. It’s on the horizon.

For now, the best thing you can do is get evaluated early. Don’t wait until you’re on dialysis. Talk to your nephrologist. Ask about transplant. Find out if you qualify. And if you’re healthy enough, consider becoming a living donor. One kidney can give someone back their life.