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

Getting Evaluated for a Kidney Transplant

When your kidneys are failing, a transplant isn’t just a next step-it’s often your best shot at a longer, healthier life. But before you can even get on the waitlist, you need to go through a detailed medical and personal evaluation. This isn’t a quick checkup. It’s a full picture of your health, your life, and your ability to handle life after a transplant.

The process starts when your nephrologist sees that your eGFR has dropped below 20 mL/min/1.73m². That’s the signal it’s time to talk to a transplant center. You’ll be assigned a transplant coordinator who becomes your main point of contact. They’ll walk you through every step, but you need to be ready. Bring all your medical records-five years’ worth, including dialysis logs if you’ve had them. Show up with someone who can help you remember details and ask questions.

You’ll go through 15 to 25 appointments over 8 to 16 weeks. Blood tests check your type, liver and kidney function, and screen for viruses like HIV and hepatitis. You’ll get a full cardiac workup: EKG, chest X-ray, echocardiogram, and a stress test to make sure your heart can handle surgery. Women over 40 need mammograms and Pap smears; men over 50 need PSA tests. Your immune system is tested too-HLA typing and PRA levels show how likely your body is to reject a new kidney.

There are hard limits. If you have active cancer, uncontrolled infection, severe heart disease, or a BMI over 40, you won’t be listed. But it’s not just about your body. Your mental and emotional readiness matters just as much. A social worker will sit down with you to talk about your support system. Do you have someone to drive you to appointments? Can you afford medications? Do you understand that you’ll need to take immunosuppressants every single day for the rest of your life?

One in three people who start the process don’t make it to the waitlist-not because their kidneys are too bad, but because they can’t meet these non-medical requirements. Insurance issues are a huge roadblock. Medicaid patients wait 37 days longer on average than those with private insurance. Even with coverage, out-of-pocket costs for testing can hit $8,000. If you’re denied a test, push back. Ask for help from your coordinator or patient advocacy groups.

Getting on the Waitlist

Once your evaluation is complete, the transplant committee meets-usually weekly-to review your case. They include a surgeon, nephrologist, social worker, psychiatrist, and coordinator. Their job isn’t just to approve you. It’s to make sure you’re not just eligible, but ready.

If you’re approved, you’re added to the national waitlist. As of January 2024, over 102,000 people in the U.S. are waiting for a kidney. The average wait time? Three and a half years. That’s not just a number. It’s years of dialysis, missed work, and constant uncertainty.

But not everyone waits the same. Your wait time depends on your blood type, how sensitized your immune system is, and where you live. If you have high levels of antibodies (cPRA ≥98%), you get priority. This helps people who’ve had previous transplants or blood transfusions, who often struggle to find matches.

What you can’t control is the donor supply. Deceased donor kidneys are scarce. But there’s another path-one that can cut your wait time dramatically: a living donor.

Living Donors: The Faster Path

Living donor transplants make up nearly 40% of all kidney transplants in the U.S. That’s because a healthy person can live with one kidney. And when you get a kidney from someone alive, the results are better. One-year graft survival is 96.3% for living donor transplants, compared to 94.1% for deceased donors.

The process for a living donor is almost as rigorous as yours. They need to be physically healthy, emotionally stable, and fully informed. They’ll go through the same blood tests, imaging, and psychological screening. Their kidney function, blood pressure, and overall health are checked in detail.

Here’s the big advantage: you don’t have to wait for a match to become available. If someone is willing to donate to you, the transplant can happen on your schedule. At top centers, donor evaluations are now streamlined-some take as little as two to three weeks thanks to rapid crossmatch technology.

But not everyone has a friend or family member ready to donate. That’s where paired donation programs come in. If your loved one wants to give you a kidney but isn’t a match, they can donate to someone else-and you get a kidney from someone else’s donor. In 2023, over 1,800 transplants happened this way.

Don’t assume someone won’t be able to donate because of age or minor health issues. Many people over 60 are now eligible donors. Even people with mild high blood pressure or a history of kidney stones have successfully donated after careful review.

What Gets You Off the Waitlist

It’s not just about passing tests. The biggest reasons people don’t get listed aren’t medical-they’re human.

According to transplant experts, 32% of evaluation failures are due to psychosocial reasons: lack of support, unstable housing, substance use, or inability to commit to lifelong medication. Medical issues like cancer or heart disease account for 28%. But the biggest single reason? Non-adherence history. If you’ve missed dialysis appointments, skipped medications, or ignored doctor’s advice, centers will hesitate. They need to know you’ll take care of the new kidney.

Other common deal-breakers: uncontrolled diabetes, active smoking, or obesity. If you’re overweight, many centers will require you to lose weight before listing. If you smoke, you’ll need to quit-at least six months before evaluation.

And yes, race still plays a role. Black patients wait longer on average-28.4% longer-than white patients. But centers using standardized pathways have cut that gap to just 12.1%. If you’re being delayed, ask why. Push for transparency.

What Happens After You’re Listed

Being on the waitlist doesn’t mean you’re done. You need to stay ready. Keep your contact info updated. Tell your coordinator if you move, change phones, or get sick. Make sure your insurance is still active. Missing a test or letting your coverage lapse can delay your listing.

Medicare covers 80% of transplant costs under Part B, and Part D helps with drugs. But you still need to plan for $32,000 a year in medication costs after transplant. Most centers require proof you can afford this before listing. If you can’t, ask about financial aid programs. The American Kidney Fund and National Kidney Foundation offer grants for transplant-related expenses.

Stay active. Keep your body as healthy as you can. Walk. Eat well. Don’t gain weight. Avoid infections. Every day you stay healthy is a day closer to transplant.

How to Speed Up the Process

You can’t control the donor pool. But you can control how fast you move through evaluation.

• Complete your paperwork within 14 days of being referred. Delays here can add weeks.
• Bring the same person to every appointment. They’ll help you remember what was said and ask the right questions.
• Use your patient portal. Track your test results. Don’t wait for a call-check online.
• Call your coordinator weekly. They manage 45 to 60 patients. If you don’t follow up, you get lost in the pile.
• If insurance denies a test, appeal immediately. Don’t wait.
• Start talking to family and friends about donation. You’d be surprised who’s willing.

People who finish evaluation in 90 days are 22.7% more likely to get a transplant within two years. That’s not a small edge. That’s life-changing.

What You Need to Know Before You Say Yes

A transplant isn’t a cure. It’s a lifelong commitment. You’ll take pills every day. You’ll have blood tests every few weeks. You’ll need to avoid crowds during flu season. You’ll worry about rejection. You’ll feel guilty if your donor has complications.

But it’s also freedom. Freedom from dialysis. Freedom to travel. Freedom to sleep through the night. Freedom to work, to play, to be present for your family.

Most people who get transplants say they wish they’d done it sooner. Don’t wait until you’re desperate. Start the conversation now. Start the evaluation now. Your next kidney might be waiting-right next to you.