What Is a Kidney Transplant? From Evaluation and Waiting to Surgery and Lifelong Care

What Is a Kidney Transplant?

A healthy kidney — from a living or deceased donor — is surgically placed into a person with kidney failure.

Common misconceptions:

• The original kidneys usually stay. The new kidney goes in the lower abdomen (iliac fossa), connected to the iliac vessels and bladder. Native kidneys are removed only in special cases.
• Transplant is not a cure; it swaps one chronic state for another: from "uremia plus dialysis" to "normal kidney function plus lifelong immunosuppression."
• One kidney is enough for a normal life.

Why Is Transplant Preferred?

Even accounting for surgical risk, transplant recipients have lower long-term mortality than wait-listed dialysis patients.

Donor Sources

Deceased donation

• Brain death (DBD): Taiwan's main source; circulatory death (DCD) permitted since 2017
• Allocation by the Taiwan Organ Registry and Sharing Center, ranked by blood type, tissue match, waiting time, age
• About 8,000–9,000 people wait; only 200–300 deceased-donor kidney transplants per year; waits often exceed 5–10 years

Living donation

• Taiwan law: blood relatives within five degrees or spouse (married ≥ 2 years or with children)
• Paired kidney exchange permitted since 2019
• Advantages: short wait, scheduled surgery, better survival (US SRTR: 5-year graft survival in recipients aged 18–34 is 89.9% living vs. 82.5% deceased)
• Enables preemptive transplant before dialysis
• Healthy donors have long-term kidney function and lifespan similar to the general population, with lifelong follow-up

Matching

• ABO: same rules as transfusion; ABO-incompatible transplants now possible with pre-transplant plasmapheresis
• HLA: six antigens (A, B, DR); better match is better, but modern drugs reduce its impact
• Crossmatch: detects donor-specific antibodies (DSA); positive usually rules out transplant
• PRA: prior transfusion, pregnancy or transplant raises antibodies ("sensitization"), making matching harder

Recipient Evaluation

Cardiovascular (ECG, echo, stress test if high-risk), infection screening (hepatitis B/C, HIV, TB, CMV, EBV), cancer screening (prior cancer requires 2–5-year disease-free interval), urinary tract, dental, psychosocial (adherence, support), immunology (blood type, HLA, PRA). Age alone is not a contraindication.

Surgery

• General anesthesia, 3–4 hours; kidney placed in the iliac fossa
• Hospital stay 7–14 days
• Delayed graft function (DGF): dialysis still needed in week one; 20–30% of deceased-donor transplants, most recover within 1–3 weeks

Rejection

Rejection is often silent — detected by routine labs (rising creatinine), urinalysis, and biopsy. Never skip follow-up.

Immunosuppression

Induction: basiliximab or ATG. Maintenance (lifelong) triple therapy:

1. Tacrolimus (or cyclosporine): trough monitoring; nephrotoxicity, hypertension, raised glucose, tremor
2. Mycophenolate: diarrhea, low white cells, teratogenic (switch before pregnancy)
3. Prednisolone: tapered; glucose, blood pressure, osteoporosis

Iron rules

• On time, never skipped, never self-adjusted
• Interactions: grapefruit, pomelo, starfruit, St John's wort, certain antibiotics and antifungals, herbal products all alter tacrolimus levels. Ask before any new drug or supplement
• On drug-level test days, blood draw first, then take the dose

Long-Term Risks and Care

Infection

• Month 1: surgical; months 1–6: opportunistic peak (CMV, BK virus, PJP) with routine prophylaxis; after 6 months: community infections
• Vaccines: inactivated recommended; live attenuated (MMR, varicella, yellow fever) prohibited after transplant

Cancer

Risk about 2–3× general population: skin cancer (sun protection, annual checks), PTLD (EBV-related), urothelial cancer (relatively common in Taiwan), liver, cervical. Regular screening matters more.

Cardiovascular and metabolic

• Post-transplant diabetes: 10–30%, mainly from tacrolimus and steroids
• Hypertension, dyslipidemia, obesity

Graft monitoring

Creatinine/eGFR, proteinuria, BK virus (first 2 years), DSA, recurrence of original disease (FSGS, IgA nephropathy).

Bone and fertility

Steroids raise osteoporosis risk; monitor bone density. Women often regain fertility; pregnancy advised after ≥ 1 year of stability, and mycophenolate must be stopped before conception.

Daily life

• Diet: potassium/phosphate restrictions mostly lifted; food safety (no raw foods); avoid grapefruit-type fruits
• Exercise: avoid abdominal strain 6–8 weeks, then regular exercise; avoid impact to the graft area
• Work: most return within 2–3 months
• Travel: split medication, English medical summary, consult beforehand

How Long Does a Graft Last?

• Deceased-donor: median 10–15 years
• Living-donor: 15–20 years
• Some last 25–30+ years
• After failure: dialysis or retransplant

Key Takeaways

1. Transplant offers the best survival and quality of life, but requires lifelong immunosuppression and follow-up
2. Deceased (long wait) vs. living (better outcomes, preemptive possible)
3. Rejection is usually silent — routine labs and biopsy detect it
4. Medication adherence and interaction awareness are the first rule
5. Three major long-term risks: infection, cancer, cardiometabolic disease
6. Grafts have a finite lifespan; dialysis or retransplant remain options

References

• KDIGO. Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020.
• KDIGO. Clinical Practice Guideline for the Care of Kidney Transplant Recipients. Am J Transplant. 2009.
• KDIGO. Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. 2017.
• OPTN/SRTR. 2024 Annual Data Report: Kidney. HRSA.
• NIDDK. Kidney Transplant.
• Taiwan Organ Registry and Sharing Center. Annual reports.
• Taiwan Ministry of Health and Welfare. Human Organ Transplant Act.
• Taiwan National Health Insurance Administration. Transplant survival statistics.

This article summarizes publicly available medical information for educational purposes only and is not medical advice. For any questions about your health, illness or physical care, please seek help through professional medical channels and consult your physician.