Preparing for a Kidney Transplant: Evaluation, Waitlist, and Living Donors

Getting Evaluated for a Kidney Transplant

When your kidneys are failing, a transplant can give you back years of life - but getting one starts long before surgery. The evaluation process is not a single appointment. It’s a detailed, multi-step medical and personal review that can take weeks or even months. You’ll meet with nephrologists, surgeons, social workers, financial counselors, and psychologists. Each person is looking at a different piece of your life: your body, your support system, your ability to follow complex medication routines, and your financial readiness.

The process usually begins when your nephrologist notices your eGFR (a measure of kidney function) has dropped below 20 mL/min/1.73m². That’s the signal that transplant should be considered. Once referred, you’ll be assigned a transplant coordinator who becomes your main point of contact. They’ll guide you through the checklist: medical tests, paperwork, insurance approvals, and education sessions. You’ll learn what happens after transplant - the lifelong need for anti-rejection drugs, the risk of infections, and the importance of regular blood tests.

There are 27 key lab values that centers check. Your hemoglobin must be above 10 g/dL, platelets above 100,000/μL, and albumin above 3.5 g/dL. Liver enzymes, kidney function markers, and viral screenings for HIV, hepatitis B and C are mandatory. You’ll also need a cardiac workup: an echocardiogram to check your heart’s pumping strength (ejection fraction must be at least 40%), an EKG, a chest X-ray, and a stress test where you walk on a treadmill to see if your heart can handle the strain of surgery.

Women over 40 need mammograms and Pap smears. Men over 50 need PSA tests. These aren’t optional - they’re about making sure you don’t have hidden cancers that could worsen after transplant. If you’ve had cancer in the past five years, you may be ineligible unless it’s been in complete remission for a specific time. Centers are strict because transplant drugs weaken your immune system, making it harder to fight off cancer.

What Happens on the Waitlist

Once you pass evaluation, you’re added to the national kidney waitlist. As of January 2024, over 102,000 people in the U.S. were waiting. The average wait time? About 3.6 years. But that number means little without context. Your actual wait depends on your blood type, how sensitized your immune system is, and where you live.

If you have blood type O, you can only receive kidneys from other type O donors - and those are the rarest. If you’ve had previous transplants, pregnancies, or blood transfusions, your body may have developed antibodies that attack most donor kidneys. This is measured as your cPRA (calculated Panel Reactive Antibody). If your cPRA is above 98%, you’re considered highly sensitized. The new OPTN allocation system gives you priority over others with lower cPRA levels, even if you’ve been waiting longer.

But being on the list doesn’t mean you’re guaranteed a kidney. You must stay medically eligible. If you gain too much weight, develop a new infection, or stop taking your medications, you can be temporarily removed. Centers check in every few months. You’ll need updated blood work, heart tests, and sometimes repeat psychological evaluations. Missing appointments can delay your listing or even lead to removal.

Insurance is a huge part of staying on the list. Medicare covers 80% of transplant costs under Part B, and Part D covers your anti-rejection drugs. But if you’re on Medicaid, you might face longer delays - studies show Medicaid patients wait 37 extra days just to get approved for testing. Insurance denials for specific tests happen in 24% of Medicaid cases. You need to fight those denials immediately. Your transplant coordinator can help, but you must be your own advocate. Keep records of every call, every denial letter, every appeal.

Living Donors: The Fastest Path

Living donor transplants are the best option - and they’re growing. In 2023, nearly 40% of all kidney transplants came from living donors. Why? Because kidneys from living donors last longer, work better right away, and you don’t have to wait years on a list. The median wait for a deceased donor kidney is over three years. With a living donor, you can have surgery within weeks or months.

Donors can be family, friends, coworkers - even strangers. The process for them is just as thorough as yours. They need to be healthy: no diabetes, no high blood pressure, no history of kidney disease. Their BMI must be under 35. They’ll go through the same blood tests, viral screens, and heart checks. They’ll also meet with a social worker and a psychiatrist to make sure they’re not being pressured and truly understand the risks.

There’s a special program called Kidney Paired Donation (KPD). If your friend wants to donate but their blood type doesn’t match yours, they can give to someone else who does match - and in return, you get a kidney from someone else’s donor. In 2023, this program helped 1,872 people get transplants. It’s like a chain reaction. One donor starts it, and multiple people benefit.

At top centers, donor evaluation has been cut from 6-8 weeks down to 2-3 weeks using rapid crossmatch protocols. This means less stress, fewer appointments, and faster surgery. But it’s not easy. Donors often take unpaid time off work, pay for travel, and face out-of-pocket costs for things like parking, meals, and lost wages. Some centers help with these expenses, but not all. Make sure you ask.

Why People Don’t Make It to Transplant

Not everyone who starts the process ends up on the list. About 1 in 5 candidates get rejected. The top reasons aren’t always what you’d expect. The biggest one? Psychosocial issues - not medical ones. In fact, 32% of evaluations fail because of problems like lack of support at home, unreliable transportation, or inability to afford medications. That’s more than heart disease, cancer, or obesity.

Here’s the hard truth: if you don’t have someone who can drive you to appointments, help you take your pills, or stay with you after surgery, you may be denied. It’s not that centers don’t care. It’s that transplant failure after surgery is devastating. And if you miss doses of your anti-rejection drugs, your new kidney can fail in months.

Other common reasons: uncontrolled high blood pressure, active infections, or a history of not following medical advice. Even if you’re healthy now, if you’ve missed dialysis appointments in the past, centers will worry. They need to know you’ll follow through after transplant.

And then there’s money. The cost of transplant medications averages $32,000 a year. Most centers require proof you can cover at least $3,500 in out-of-pocket costs for the first year. If you can’t show that, you’ll be asked to get financial help - through charities, state programs, or hospital assistance. The American Kidney Fund and National Transplant Foundation offer grants. Apply early.

How to Succeed in the Process

There’s no magic trick. Success comes down to three things: organization, communication, and persistence.

• Keep a binder or digital folder with all your medical records - at least five years’ worth. Include dialysis logs, lab reports, hospital discharge summaries, and your medication list. Bring it to every appointment.
• Bring a support person to every visit. One person can take notes, ask questions you forget, and help you remember what was said. Don’t go alone.
• Track your appointments on a calendar. Missed appointments delay your evaluation. Northwestern Medicine found that 18% of delays happen because someone didn’t show up.
• Ask questions - even if they feel dumb. What happens if I get sick after transplant? Can I still work? What if I want to travel? The more you understand, the better your chances.
• Start insurance appeals immediately. If a test is denied, call the insurance company. Ask for a written denial. Then call your transplant center - they have advocates who can help you appeal.
• Don’t wait. Studies show people who finish evaluation within 90 days of their first referral are 11% more likely to survive five years after transplant. The clock starts the day your nephrologist refers you.

There are success stories. One patient on Reddit, KidneyChamp99, got all 19 of their appointments scheduled in six weeks because their coordinator grouped tests by location. Another, RenalWarrior87, spent 11 weeks and 17 appointments - but kept going. They got their transplant. You can too.

What Comes After the Waitlist

When your name comes up for a kidney, you’ll get a call - often in the middle of the night. You’ll be told to come to the hospital immediately. No time to pack. No time to think. You’ll be rushed in, checked again, and taken to surgery. If it’s a living donor, you’ll schedule the date together. You’ll both be prepped at the same time.

After surgery, you’ll stay in the hospital for 3-7 days. Then comes the real work: taking your meds every single day, never skipping a dose. You’ll have blood tests twice a week at first. You’ll learn to recognize signs of rejection: fever, swelling, pain near the transplant, sudden weight gain. You’ll be told to avoid raw meat, unpasteurized cheese, and people who are sick. You’ll need to wash your hands constantly.

But it’s worth it. One-year survival rates for living donor transplants are 96.3%. For deceased donor transplants, it’s 94.1%. Most people go back to work, travel, play with their grandchildren. They sleep better. They eat what they want. They feel like themselves again.

It’s not easy. But if you’re ready to fight for your health, the system can work for you. Start now. Don’t wait for the perfect moment. There won’t be one.