Medically reviewed by the Know Your Surgery Editorial Team. Last reviewed: May 2026.
A kidney transplant is recommended when a patient has end-stage kidney disease (ESKD) or is approaching it, and when the patient is medically and psychosocially suitable for transplant. This article explains what causes kidney failure, how transplant centers evaluate candidates, and how the decision to proceed with transplant is made. If you are new to the topic, the cluster overview article is a useful starting place.
What Causes Kidney Failure?
Chronic kidney disease (CKD) progresses over years and can lead to kidney failure. Several causes are recognized in the United States.
Diabetes. The leading cause of kidney failure in the US. High blood sugar damages the small blood vessels in the kidneys over years.
High blood pressure. The second most common cause. Persistent high blood pressure damages kidney filters.
Glomerulonephritis. Inflammation of the kidney’s filtering units. Includes IgA nephropathy, lupus nephritis, and others.
Polycystic kidney disease (PKD). An inherited condition where many fluid-filled cysts develop in the kidneys.
Recurrent or severe urinary tract problems. Chronic infections, obstruction, or reflux.
Autoimmune diseases. Lupus, ANCA-associated vasculitis, and others.
Genetic conditions. Alport syndrome, cystinosis, primary hyperoxaluria, and others.
Long-term medication exposure. Certain medications can damage the kidneys over time.
Birth defects. Congenital abnormalities of the urinary tract.
Heart and liver disease. Severe chronic disease in these organs can affect kidney function.
Identifying the cause helps the team plan transplant care, including risk of recurrence in the new kidney.
Risk Factors That Increase the Likelihood of Kidney Failure
Several factors raise the likelihood of progressing to kidney failure:
- Diabetes, especially with poor blood sugar control
- Uncontrolled high blood pressure
- Family history of kidney disease
- Older age
- Smoking
- Obesity
- Heart disease
- Race and ethnicity (some groups have higher rates of certain causes)
Early detection and treatment can slow progression in many patients.
Symptoms Suggesting Advanced Kidney Disease
Kidney disease is often silent until late stages. Common signs of advanced disease include:
- Persistent swelling in the legs, ankles, or face
- Decreased urine output
- Foamy or bubbly urine
- Severe fatigue
- Trouble concentrating
- Persistent itching
- Loss of appetite, nausea, or vomiting
- Muscle cramps, especially at night
- Trouble sleeping
- Anemia (low red blood cells)
- High blood pressure that is hard to control
Severe symptoms that require immediate evaluation:
- Chest pain or shortness of breath
- Severe swelling
- Confusion or extreme drowsiness
- Severe vomiting that prevents fluid intake
These symptoms can suggest advanced kidney failure or fluid overload. Patients with known kidney disease should have an emergency contact at their nephrology clinic.
How Clinicians Diagnose and Stage Kidney Disease
When kidney disease is suspected or known, the team typically follows a structured evaluation.
Detailed history. The clinician asks about prior kidney problems, family history, diabetes, blood pressure, medications, and symptoms.
Physical examination. Includes blood pressure, weight, and assessment of swelling.
Blood tests. A creatinine level allows calculation of the estimated glomerular filtration rate (eGFR), which estimates kidney function. Other labs check electrolytes, calcium, phosphorus, hemoglobin, and parathyroid hormone.
Urine tests. A urine sample checks for protein, blood, and other markers. The urine albumin-to-creatinine ratio (UACR) is especially important.
Imaging studies. Kidney ultrasound is the most common test. CT or MRI may be used in select cases.
Kidney biopsy. Sometimes needed to clarify the cause of kidney disease.
Staging. Chronic kidney disease is staged from G1 (normal eGFR) to G5 (kidney failure, eGFR less than 15). Patients with G5 typically need dialysis or transplant.
Differential Diagnosis
Many conditions can affect kidney function, and identifying the right cause is essential before transplant. Common entities considered include:
- Diabetic kidney disease
- Hypertensive kidney disease
- Glomerulonephritis
- Polycystic kidney disease
- Obstructive uropathy
- Acute kidney injury (which may not need transplant if reversible)
- Multiple myeloma
- Hereditary kidney diseases
The diagnostic workup helps the team distinguish these conditions and plan care.
Initial Management of Kidney Disease
Before transplant, most patients receive structured care to slow progression and manage symptoms:
- Blood pressure control (often with ACE inhibitors or ARBs)
- Blood sugar control for patients with diabetes
- Cholesterol management
- Anemia management (often with erythropoiesis-stimulating agents and iron)
- Bone and mineral management
- Dietary counseling
- Avoidance of nephrotoxic medications
- Vaccinations including hepatitis B, pneumococcal, and influenza
- Cardiovascular screening
When kidney function approaches the threshold for ESKD, patients are referred for transplant evaluation.
When to Consider a Kidney Transplant
A kidney transplant is generally considered when:
- The patient has ESKD (eGFR less than 15 mL/min) or is approaching it
- The patient is medically suitable for transplant surgery and immunosuppression
- The patient is psychosocially prepared for the lifelong care after transplant
- A donor (living or deceased) is or will be available
- The expected benefit of transplant outweighs the risks
Some patients are not candidates due to:
- Severe heart, lung, or liver disease that makes surgery too risky
- Active cancer (a waiting period is often required after cancer treatment)
- Active substance use that interferes with medication adherence
- Untreated mental illness that interferes with care
- Severe vascular disease that prevents safe transplant
- Active infection
The decision is made by a multidisciplinary transplant team and shared with the patient.
How the Decision Is Made
The choice depends on several factors:
Medical suitability. Heart, lung, kidney, vascular, and infection assessment.
Psychosocial suitability. Adherence, support system, mental health, and ability to manage complex medications.
Donor availability. Living donor, paired exchange, or deceased-donor waiting list.
Patient preferences. Some patients prefer to start with dialysis and consider transplant later.
Insurance and financial factors. Most transplants are covered, but financial counseling is important.
Center-specific criteria. Each transplant center has guidelines on age, body mass index, and other factors.
For most patients, the conversation also covers the realities of post-transplant life: lifelong medications, regular follow-up, and the possibility (uncommon) of rejection.
Pre-Transplant Evaluation
The evaluation is thorough and typically includes:
- Detailed medical history and physical
- Blood tests (kidney function, blood typing, tissue typing, virology, antibody testing)
- Cardiac evaluation (EKG, echocardiogram, stress test, sometimes catheterization)
- Pulmonary evaluation (chest X-ray, sometimes pulmonary function tests)
- Cancer screening (colonoscopy, mammogram, prostate, skin)
- Infection screening (HIV, hepatitis, tuberculosis, others)
- Dental evaluation
- Mental health and social work consultation
- Financial counseling
- Patient and family education sessions
For living donors, a parallel evaluation confirms the donor’s health and willingness.
The procedure itself, the recovery, and the home recovery period are covered in detail in our procedure and recovery article.
Conditions That May Affect the Surgical Plan
Some coexisting conditions can change how a kidney transplant is performed:
- Severe vascular disease. May affect where the kidney can be placed.
- Prior abdominal surgery. May complicate the surgical approach.
- Heart, lung, or liver disease. May require additional pre-op evaluation or treatment.
- Diabetes. Insulin and blood sugar plans are coordinated.
- Obesity. Some centers have BMI thresholds for transplant.
- Hypersensitization (high antibody levels) in the recipient.
- Polycystic kidney disease. Sometimes the patient’s own kidneys must be removed before or after transplant.
The team accounts for these factors when planning the transplant.
What Happens After You Decide
Once a kidney transplant is on the path forward, the team prepares the recipient (and donor, if applicable). The surgery itself, the recovery in the hospital, and the home recovery period are covered in detail in our procedure and recovery article.
The conversation with your transplant team is detailed but important. Key things to confirm: surgical plan, donor source, immunosuppression plan, expected hospital stay, follow-up schedule, support system at home, and emergency contact for after surgery.
Continue Reading the Kidney Transplant Cluster
- Kidney Transplant: Overview, Types, and What to Expect
- Kidney Transplant: Procedure, Recovery, and Rehabilitation
- Kidney Transplant: FAQs, Statistics, and Patient Stories
Sources
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Kidney transplant. https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/kidney-transplant
- Centers for Disease Control and Prevention (CDC). Chronic kidney disease basics. https://www.cdc.gov/kidney-disease/about/
- Organ Procurement and Transplantation Network (OPTN). Kidney transplant data. https://optn.transplant.hrsa.gov/
- United Network for Organ Sharing (UNOS). Kidney transplant resources. https://unos.org/
- Mayo Clinic. Kidney transplant evaluation. https://www.mayoclinic.org/tests-procedures/kidney-transplant/about/pac-20384777
- Cleveland Clinic. Kidney transplant evaluation. https://my.clevelandclinic.org/health/treatments/17498-kidney-transplant
Medical Disclaimer
The information in this article is for general education and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about kidney disease or kidney transplant evaluation.
