Kidney Transplant 101: Notes from conversations with kidney transplant surgeons

Published on: 03/21/2023

Kidney transplant is a big process that can seem scary at first, but does not have to be. Doing research and being informed before starting the transplant process can remove some of the fear. 

Kidney Transplant Process

There are many steps in the kidney transplant process and some of them may vary by transplant center, but overall they are pretty similar.

Transplant Referral

Referral is the first step in the transplant process. Kidney transplant surgeons will not typically evaluate an individual until after they are CKD stage 5, with eGFR less than 15. This does not mean that one needs to be on dialysis prior to being listed. The nephrology clinic or dialysis clinic will refer the patient to the transplant team. From there, a transplant coordinator will begin to evaluate the patient’s chart and may schedule them for an evaluation.

Kidney Transplant Criteria: The Evaluation

The kidney transplant evaluation process can take place over one or two very busy days or can be stretched over months of individual appointments. The distance the patient is traveling will factor into the evaluation schedule. If someone is traveling from a long distance, the team will evaluate over a couple days to limit extra travel. 

Transplant Team


The transplant coordinator is the gatekeeper in many ways to the transplant process. They serve as the liaison to the medical review board (MRB), more on that in a moment, the patient and the care team. Some transplant coordinators are more helpful than others, but it is important that there be a working relationship between the coordinator and the patient. The coordinator is responsible for communicating any remaining requirements the patient must complete to be listed.


The kidney transplant surgeon is the one that actually performs the kidney transplant. He or she will be involved in the transplant evaluation but not to the level that other members of the team are.


The transplant dietitian will assess the patient and any potential living donor to ensure that they are of good nutritional status for transplant. There are very few organs available for the number of individuals waiting and it is essential that individuals receiving a transplant are not considered frail. The assessment with the dietitian will likely take at least an hour and will focus on foods typically eaten, physical measures and an assessment of frailty.

Waist measurements are being increasingly used as a measure of central adiposity to determine if an individual is a good candidate for transplant. Too large of a waistline has been associated with poor graft outcomes. The frailty assessment may vary based on transplant center but could include hand grip strength, walking and sitting to standing movements. The transplant dietitian will also ask about support systems in place for the patient. After surgery, it is likely the patient will need help preparing nutritious foods and managing medications. 

Social Worker and Psychologist

The transplant social worker and psychologist will work together to determine the mental readiness of the patient for transplant. While transplant is a fantastic gift, it comes with lifelong medications and other potential complications that it is important the patient is prepared for. The main focus of these evaluations is to make sure there is social support in place. Two sources of support are needed for transportation to appointments as there are many appointments in the first months after transplant to ensure the new organ is working properly.

Financial Team

Transplant is expensive and not all insurance covers the associated costs. The financial team is responsible for reviewing the insurance coverage and informing the patient of the costs associated with transplant and medications following. Patients have been denied transplant listing due to financial concerns, so it is important to take this piece seriously.

Medical Review Board

The Medical Review Board or MRB is the meeting of all the above team members to determine if an individual is to be listed, whether active or inactive. There are several options for the outcome of this meeting:

  1. Active: will receive an organ when they are at the top of the list
  2. Inactive: may have additional testing to complete or may not currently be in stage 5/dialysis. In this stage, time towards transplant is still accumulated.
  3. Pending: additional testing needed to determine if transplant is safe. This could be a mammogram, heart test or other piece to ensure the recipient is healthy enough for the organ. 
  4. Denied: the individual is not to be listed at this time. This does not mean the patient can never be listed, but they will need to go through parts, or all, of the process again at a later date. A reason for denying transplant listing is required.

Kidney Transplant Waiting List

Once listed actively, the wait begins. Depending on a variety of factors, the wait can be years or many months. Communicating with the transplant coordinator about travel if actively listed is imperative as an organ can become available at any time. If travel is planned, the patient can be made inactive for the time of the travel without losing their place in line or status. Annual update evaluations are needed to make sure there have not been any big changes to health status that could impact listing. These annual updates are usually not as long as the initial evaluation process. 

Transplant Surgery

CONGRATS! A donor has been found and surgery is scheduled very quickly. This can be a whirlwind for patients but is so very exciting. 

Kidney Transplant Recovery

Recovering from transplant takes many months. The initial phase of recovery in the hospital requires many changes to nutrition and medications as the new organ begins to filter blood. Many patients mention the amount of fluid they are asked to drink in the first hours and days after transplant to be a big shock after many have been restricted while on dialysis for years.

Kidney Transplant Requirements

Every center has their own requirements that may vary from one to another. The best way to research outcomes and requirements is to do your homework.

Transplant Center Research

The Scientific Registry of Transplant Recipients or SRTR is a great place to look at transplant outcomes for each center and each organ. There are several things to look for within the full reports provided. Before checking out the full reports, looking at the number of transplants performed and the outcomes of those transplants can give a good indication of the quality of the program. Diving into the reports can provide more insight into BMI, age and other characteristics of the recipients. 

The transplant process can be overwhelming but it doesn’t have to be. I break down all things transplant in my dialysis course. This course is designed for anyone that is either on dialysis and feeling overwhelmed or preparing for dialysis and really wanting to dive deep into nutrition while on dialysis. Check out more about the Dialysis Essentials Course, coming soon.


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