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

Getting Evaluated for a Kidney Transplant

If your kidneys are failing and you’re on dialysis-or close to it-your doctor may talk to you about a kidney transplant. It’s not just a surgery. It’s a long process that starts with a thorough medical and personal review called transplant evaluation. This isn’t a quick checkup. It’s a full picture of your health, your life, and whether you’re ready for a transplant now and years down the road.

Most transplant centers begin this process when your estimated glomerular filtration rate (eGFR) drops below 20 mL/min/1.73m². That’s when your kidneys are working at less than 20% of normal capacity. But getting evaluated doesn’t mean you’re automatically added to the waitlist. You have to pass a series of tests, interviews, and approvals.

The evaluation usually takes between 12 and 16 weeks for someone waiting for a deceased donor kidney. If you have a potential living donor, the timeline can be faster-sometimes as short as 6 to 8 weeks-because the center can evaluate both of you at the same time. But speed depends on how quickly you complete every step. Missing an appointment or not returning paperwork can delay things by weeks.

You’ll meet with a team: a nephrologist, transplant surgeon, social worker, psychologist, financial counselor, and transplant coordinator. Each has a job. The doctor checks your heart, liver, and kidney function. The social worker asks about your home life, your support system, and whether you can get to appointments. The psychologist looks at your mental health-how you handle stress, whether you’re likely to take your medicines every day after the transplant. And the coordinator? They’re your main point of contact. They schedule everything, track your results, and answer your questions.

There are 27 standard lab tests required. Your blood must show:

• Hemoglobin above 10 g/dL
• Platelets over 100,000/μL
• Serum albumin higher than 3.5 g/dL
• No active infections like HIV, hepatitis B or C

You’ll also need a cardiac stress test to prove you can handle the physical strain of surgery. If your heart can’t manage 5 metabolic equivalents (roughly walking up stairs quickly), you might need treatment first. Women over 40 need a mammogram and Pap smear. Men over 50 need a PSA test. All of this is to make sure you’re healthy enough to survive the surgery and thrive afterward.

What Gets You Off the Waitlist

Not everyone who starts the evaluation gets listed. About 1 in 4 people don’t make it to the waitlist. And it’s not always because of a serious illness.

The top five medical reasons people are turned down:

• Active cancer (14.2%)
• Severe heart disease (11.8%)
• Uncontrolled infection (9.3%)
• Severe obesity (BMI over 40, 8.7%)
• History of missing dialysis or medications (7.9%)

But here’s something many don’t realize: psychosocial factors cause more failures than medical ones. About 32% of candidates are denied because of issues like lack of support at home, unstable housing, inability to afford medications, or concerns about following a strict post-transplant routine. One patient on Reddit said their psychosocial interview felt like being interrogated. But the team isn’t judging you-they’re trying to figure out if you’ll be able to stick with the lifelong medicine schedule after the transplant.

Transplant centers don’t list you until every single test is done. No shortcuts. No partial reviews. One center reported that 12.3% of evaluations get canceled because someone skipped a test or didn’t return forms. If you’re serious about this, treat every appointment like a job interview-show up on time, bring your records, and ask questions.

Insurance is another big hurdle. Medicare covers 80% of transplant costs, but you’ll still need a Part D plan for your anti-rejection drugs. Private insurance covers 70-90%, but deductibles average $4,550 a year. Medicaid patients often wait 37 days longer just to get through the evaluation because of paperwork delays. If your insurance denies a test, appeal it. Don’t wait. Some centers have financial counselors who can help you navigate this.

What Happens When You’re Listed

Once you’re approved and added to the national waitlist, you’re one of 102,345 people waiting for a kidney as of early 2024. The average wait time for a deceased donor kidney is 3.6 years. But that’s just an average. Some people wait months. Others wait over a decade.

Your wait time depends on your blood type, how sensitized your immune system is, and your location. If you have high levels of antibodies (called cPRA over 98%), you’ll get priority under the new OPTN rules. That’s because your body is more likely to reject a random kidney. The system now tries to match you with kidneys that are easier for your body to accept.

But here’s the truth: waiting isn’t passive. You need to stay healthy. Keep your dialysis appointments. Eat well. Don’t gain weight. Avoid infections. If you get sick or your health changes, tell your transplant team immediately. You could be moved up or down on the list.

And don’t assume you’re stuck waiting. A living donor can change everything.

Living Donors: The Fastest Path Forward

Almost 40% of all kidney transplants in the U.S. come from living donors. That’s because one healthy person can donate a kidney and live a normal life with the other. It’s not risky for the donor-it’s safe. And for you? It’s the best possible outcome.

A living donor transplant means:

• No waiting on a list
• A kidney that works immediately
• A higher chance of long-term success-96.3% of living donor kidneys still work after one year, compared to 94.1% for deceased donors
• A chance to schedule the surgery on your terms, not when a kidney becomes available

Who can be a living donor? A family member, friend, coworker-even someone you don’t know. They don’t have to be a perfect match. Today’s technology lets us do paired exchanges. If your spouse wants to donate but isn’t compatible, they can give a kidney to someone else, and you get one from their donor’s match. In 2023, over 1,800 transplants happened this way through the Kidney Paired Donation Program.

The donor evaluation is just as strict as yours. They need to be healthy, mentally prepared, and fully informed. They’ll go through blood tests, imaging, psychological screening, and financial counseling. They can’t be pressured. No one can be paid. The law is clear: organ sales are illegal. But centers now help donors with travel, lost wages, and childcare costs-something that wasn’t common five years ago.

Some centers now use “rapid crossmatch” protocols. That cuts donor evaluation from 6-8 weeks down to just 2-3. If you have someone in mind, start the conversation early. Bring them to your first appointment. Let the team guide you both.

How to Survive the Process

This isn’t just a medical journey. It’s emotional, financial, and exhausting. Here’s what works:

• Bring someone with you. One person can’t remember everything. A partner, friend, or family member can take notes, ask questions, and help you process what you hear.
• Keep all your records. Bring 5 years of medical history: dialysis logs, hospital visits, lab results. Don’t make them hunt for your past.
• Track everything online. Most centers have patient portals. Check them daily. If a test result is pending, call the coordinator. Don’t wait.
• Ask for help with costs. The American Kidney Fund and National Transplant Foundation offer grants for evaluation expenses. You don’t have to pay $8,200 out of pocket like some patients do.
• Don’t give up if you’re denied. Sometimes, it’s not a permanent no. Lose weight. Quit smoking. Get your blood pressure under control. Reapply. Many people get approved after making changes.

And remember: completing your evaluation within 90 days of your first appointment increases your chance of getting a transplant in the next two years by over 22%. Every day counts.

What Comes After the Waitlist

If you get a call that a kidney is available, you’ll be rushed to the hospital. That’s the easy part. The real challenge starts after surgery.

You’ll take at least two anti-rejection drugs every single day-for the rest of your life. These drugs cost about $32,000 a year. You’ll need to take them at the same time, never miss a dose, and get regular blood tests to make sure the levels are right. One missed dose can lead to rejection.

Centers now require you to show you understand this before you’re listed. You’ll have to demonstrate how you’d organize your pills, set alarms, and handle a missed dose. That’s not a test of intelligence. It’s a test of commitment.

But the payoff is real. A successful transplant gives you back your life. You can eat normally. Travel. Work. Sleep through the night. No more dialysis. No more fatigue. No more constant worry.

It’s not easy. But if you’re ready to fight for it, you can get there.