Kidney transplantation is the most common type of solid organ transplantation (1).
The primary indication for kidney transplantation is:
Absolute contraindications include (2):
Comorbidities that could compromise graft survival (eg, severe heart disorders, cancer, neurodegenerative disease, advanced cirrhosis), which can be detected via thorough screening
Relative contraindications include (3):
Poorly controlled diabetes, which can lead to rapid failure of the allograft
Transplant should be delayed until unstable psychiatric conditions, substance use disorders, nonadherent behavior, certain infections and malignancies, symptomatic vascular disease, acute hepatitis, and severe hyperparathyroidism have been treated (2).
Advanced age alone is not a contraindication. Patients in their 70s and sometimes 80s may be candidates for transplants if they are otherwise healthy, functionally independent, have good social support, a reasonably long life expectancy, and are likely to experience substantial improvements in function and quality of life beyond simply being freed from dialysis. Patients with type 1 diabetes may be candidates for simultaneous pancreas-kidney or pancreas-after-kidney transplantation (see also Pancreas Transplantation).
Kidney donors
Approximately 85% of kidneys transplanted in the United States come from deceased donors (4).
About half of donated kidneys that are from deceased donors come from previously healthy, brain-dead people (donation after brain death [DBD]) (5). About one-third of these kidneys are marginal, with physiologic or procedure-related damage, but are used because demand is so great.
The other half of kidneys from deceased donors come from non–heart-beating donors (called donation-after-cardiac-death [DCD] grafts). These kidneys may have been damaged by ischemia before the donor's death, and their function is often impaired because of acute tubular necrosis; however, over the long term, they seem to function as well as kidneys from donors that meet standard criteria (called standard criteria donors [SCD]) (6).
The remaining donated kidneys (approximately 15%) come from living donors. Living donors relinquish reserve renal capacity, may put themselves at risk of procedural and long-term morbidity, and may have psychologic conflicts about donation; therefore, they are evaluated for normal bilateral kidney function, absence of systemic disease, histocompatibility, emotional stability, and ability to give informed consent. Diabetes, uncontrolled hypertension, untreated psychiatric conditions, and cancer in prospective living donors usually preclude kidney donation.
If living donor ABO matching is not feasible, sometimes ABO-incompatible transplantation can be performed; with careful selection of donors and recipients and with pretransplant treatment (plasma exchange and/or IV immune globulins [IVIG]). Outcomes of ABO-incompatible transplantation are good compared to those of ABO-compatible transplantation, with slightly higher mortality and graft loss reported in the first year, but equivalent or better overall patient and graft survival by 5 to 10 years post-transplant (7, 8, 9).
Kidney exchange programs often match a prospective donor and recipient who are incompatible with other similar incompatible pairs. When many such pairs are identified, chain exchanges are possible, greatly increasing the potential for a good match between recipient and donor. Paired donation has the added benefit of reduced reliance on desensitization protocols for ABO incompatibility, shorter waiting times, and improved outcomes compared to deceased donor kidney transplants (10, 11, 12).
General references
1. Martin F, Carmona M, Mahillo B, et al. Organ Donation and Transplantation Worldwide: The Global Observatory on Donation and Transplantation 2024 Report. Transplantation. 2026;110(3):e655-e669. doi:10.1097/TP.0000000000005657
2. Chadban SJ, Ahn C, Axelrod DA, et al. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020;104(4S1 Suppl 1):S11-S103. doi:10.1097/TP.0000000000003136
3. Stepanova M, Kumar A, Brandt P, et al. Impact of Type 2 Diabetes on the Outcomes of Solid Organ Transplantations in the U.S.: Data From a National Registry. Diabetes Care. 2023;46(12):2162-2170. doi:10.2337/dc23-1085
4. Brubaker AL, Schold JD, Schnickel GT. The Evolution of Deceased Organ Donation in the US. JAMA. 2026;335(12):1033-1036. doi:10.1001/jama.2026.0621
5. Husain SA, Motter JD, Stewart D, et al. Changes in Organ Donation After Circulatory Death in the United States. JAMA. 2026;335(12):1087-1089. doi:10.1001/jama.2026.0976
6. Butler CR, Perkins JD, Johnson CK, et al. Contemporary patterns in kidney graft survival from donors after circulatory death in the United States. PLoS One. 2020;15(5):e0233610. doi:10.1371/journal.pone.0233610
7. de Weerd AE, Betjes MGH. ABO-Incompatible Kidney Transplant Outcomes: A Meta-Analysis. Clin J Am Soc Nephrol. 2018;13(8):1234-1243. doi:10.2215/CJN.00540118
8. Massie AB, Orandi BJ, Waldram MM, et al. Impact of ABO-Incompatible Living Donor Kidney Transplantation on Patient Survival. Am J Kidney Dis. 2020;76(5):616-623. doi:10.1053/j.ajkd.2020.03.029
9. Scurt FG, Ewert L, Mertens PR, Haller H, Schmidt BMW, Chatzikyrkou C. Clinical outcomes after ABO-incompatible renal transplantation: a systematic review and meta-analysis. Lancet. 2019;393(10185):2059-2072. doi:10.1016/S0140-6736(18)32091-9
10. Ferrari P, Fidler S, Woodroffe C, Tassone G, D'Orsogna L. Comparison of time on the deceased donor kidney waitlist versus time on the kidney paired donation registry in the Australian program. Transpl Int. 2012;25(10):1026-1031. doi:10.1111/j.1432-2277.2012.01541.x
11. Hariharan S, Israni AK, Danovitch G. Long-Term Survival after Kidney Transplantation. N Engl J Med. 2021;385(8):729-743. doi:10.1056/NEJMra2014530
12. Murray J, Luke A, Wallace D, Callaghan C, Sharples LD. Comparison of outcomes after living and deceased donor kidney transplantation: UK national cohort study. Br J Surg. 2025;112(8):znaf162. doi:10.1093/bjs/znaf162
Procedure for Kidney Transplantation
The donor kidney is removed during a standard or robotic-assisted laparoscopic (or rarely, an open) procedure, perfused with cooling solutions containing relatively large concentrations of poorly permeating substances (eg, mannitol, hetastarch) and electrolyte concentrations approximating intracellular levels, then stored in an iced solution. Kidneys preserved this way function best if transplanted within 18 hours, especially in recipients > 70 years old (1). Continuous pulsatile hypothermic perfusion with an oxygenated, plasma-based perfusate, with or without donor hypothermia, has been shown to reduce graft failure relative to static cold storage and can extend ex vivo organ viability (2, 3).
For recipients, dialysis may be required before transplantation to ensure a relatively normal metabolic state, but living-donor allografts appear to survive slightly better in recipients who have not begun long-term dialysis before transplantation (4).
Recipient nephrectomy is usually not required unless native kidneys are infected.
While red blood cell transfusions can be useful for patients who have anemia, they can sensitize patients to alloantigens and thus should be avoided if possible (5, 6). Similarly, transfusions within the first 30 days after transplantation are associated with increased mortality, antibody-mediated rejection and graft failure (7).
The transplanted kidney is usually placed in the iliac fossa. Renal vessels are anastomosed to the iliac vessels, and the donor ureter is implanted into the bladder or anastomosed to the recipient ureter. Vesicoureteral reflux occurs in up to approximately 40% of adult recipients, but usually without adverse effects (8).
Immunosuppressive regimens vary (Immunosuppressants Used to Treat Transplant Rejection). An induction agent (eg, antithymocyte globulin, alemtuzumab, basiliximab) is started intraoperatively in almost all kidney transplant recipients (9). Commonly, calcineurin inhibitors (eg, cyclosporine, tacrolimus) are begun immediately after transplantation in doses titrated to minimize toxicity and rejection while maintaining trough blood levels high enough to prevent rejection. These medications are often used in combination with an antimetabolite (mycophenolate or sometimes azathioprine). On the day of transplantation, IV or oral glucocorticoids are started; dose is tapered over the following weeks depending on the protocol used.
Procedure references
1. Echterdiek F, Latus J, Döhler B, Schwenger V, Süsal C. Influence of Cold Ischemia Time on the Outcome of Kidney Transplants from Donors Aged 70 Years and Above-A Collaborative Transplant Study Report. Transplantation. 2021;105(11):2461-2469. doi:10.1097/TP.0000000000003629
2. Ma J, Ma T, Xiao P, Zhang Y, Wei H. A systematic review and network meta-analysis of preservation techniques of donor kidneys. Surgery. 2025;185:109550. doi:10.1016/j.surg.2025.109550
3. Tingle SJ, Thompson ER, Figueiredo RS, et al. Normothermic and hypothermic machine perfusion preservation versus static cold storage for deceased donor kidney transplantation. Cochrane Database Syst Rev. 2024;7(7):CD011671. doi:10.1002/14651858.CD011671.pub3
4. Mange KC, Joffe MM, Feldman HI. Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors. N Engl J Med. 2001;344(10):726-731. doi:10.1056/NEJM200103083441004
5. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease (CKD). Kidney Int. 2026;109(1S):S1-S99. doi:10.1016/j.kint.2025.06.006
6. Spensley KJ, Hassan S, Roberts DJ, et al. Transfusion-specific alloimmune responses following blood transfusion pre-kidney transplantation. Am J Transplant. 2025;25(5):1021-1029. doi:10.1016/j.ajt.2024.12.006
7. Kang M, Koh HH, Yim SH, et al. Clinical implications of early blood transfusion after kidney transplantation. Sci Rep. 2025;15(1):6827. doi:10.1038/s41598-025-90068-2
8. Margreiter M, Györi GP, Böhmig GA, Trubel S, Mühlbacher F, Steininger R. Value of routine voiding cystourethrography after renal transplantation. Am J Transplant. 2013;13(1):130-135. doi:10.1111/j.1600-6143.2012.04284.x
9. Hariharan S, Israni AK, Danovitch G. Long-Term Survival after Kidney Transplantation. N Engl J Med. 2021;385(8):729-743. doi:10.1056/NEJMra2014530
Complications of Kidney Transplantation
Complications of kidney transplant may occur immediately after surgery or may be delayed for weeks to years. Early surgical complications include bleeding, vascular thrombosis, and ureteral leakage or obstruction. Complications related to immunosuppression including infection, chronic allograft nephropathy, and cancer can occur at any time.
Rejection
Despite use of immunosuppressants, approximately 5 to 15% of kidney transplant recipients have one or more rejection episodes within the first year after transplantation (1). Most episodes are easily treated with a glucocorticoid bolus; however, they contribute to long-term graft dysfunction or failure. Signs of rejection vary by type of rejection (see table Manifestations of Kidney Transplant by Rejection Category).
Manifestations of Kidney Transplant Rejection by Category
Rejection Category | Time Frame | Mechanism | Manifestations |
|---|---|---|---|
Hyperacute | Minutes to hours | HLA incompatibility | Fever, anuria |
Accelerated | Days | Antibody mediated | Fever, oliguria, graft swelling and tenderness |
Acute | Days to week | T-cell or antibody mediated | Fever, increased serum creatinine, hypertension, weight gain, graft swelling and tenderness Appearance of protein, lymphocytes, and renal tubular cells in urine sediment |
Chronic | Months to years | T-cell or antibody mediated | Proteinuria with or without hypertension, nephrotic syndrome |
HLA = human leukocyte antigen. | |||
Nankivell BJ, Alexander SI. Rejection of the kidney allograft. N Engl J Med. 2010;363(15):1451-1462. doi:10.1056/NEJMra0902927 | |||
Rejection can be diagnosed by percutaneous needle biopsy if the diagnosis is unclear clinically. Biopsy may also help distinguish antibody-mediated from T-cell–mediated rejection and identify other common causes of graft dysfunction or failure (eg, calcineurin inhibitor toxicity, diabetic or hypertensive nephropathy, polyomavirus type 1 infection). Tests that may improve accuracy of rejection diagnosis include measurement of urinary mRNA-encoding mediators of rejection and gene expression profiling of biopsy samples using DNA microarrays.
Hyperacute rejection typically signifies failure of the transplantation.
Intensified immunosuppressive therapy (eg, with high-dose pulse glucocorticoids or antilymphocyte globulin) usually reverses accelerated or acute rejection. If immunosuppressants are ineffective, dose is tapered and hemodialysis is resumed until a repeat transplant is available.
Chronic rejection is treated based on the mechanism (antibody or T-cell mediated); it may result in graft loss and resumption of dialysis or retransplantation.
Nephrectomy of the transplanted kidney may be necessary if hematuria, graft tenderness, or fever develops after the transplanted kidney has failed.
Chronic allograft nephropathy
Chronic allograft nephropathy refers to graft dysfunction or failure ≥ 3 months after transplantation. It occurs in the majority of patients by 10 years and accounts for most late graft failure (2). Most cases are attributable to causes such as calcineurin inhibitor toxicity, diabetic or hypertensive nephropathy, or BK polyomavirus infection. Some experts believe the term should be reserved to describe graft dysfunction or failure when biopsy shows chronic interstitial fibrosis and tubular atrophy not attributable to any other cause (3).
Cancer
Compared with the general population, kidney transplant recipients are approximately 2 to 4 times more likely to develop some form of cancer (4, 5, 6), probably because the modulated immune system’s response to cancer is weakened. Cancer of the lymphatic system (lymphoma) is 30 times more common among kidney transplant recipients than the general population, but lymphoma is still uncommon. Skin cancer becomes common among kidney transplant recipients after many years of immunosuppression.
Viral infections
Cytomegalovirus, the most common opportunistic infection after transplantation, is associated with acute rejection and reduced graft survival, particularly in seronegative recipients of seropositive donor organs (1).BK polyomavirus can cause progressive nephropathy and graft failure, while Epstein-Barr virus (EBV) infection is the principal risk factor for post-transplant lymphoproliferative disorder, especially in EBV-seronegative recipients. Respiratory viral infections, including influenza and COVID-19, are also associated with a higher mortality among kidney transplant recipients.
Complications references
1. Hariharan S, Israni AK, Danovitch G. Long-Term Survival after Kidney Transplantation. N Engl J Med. 2021;385(8):729-743. doi:10.1056/NEJMra2014530
2. Li C, Yang CW. The pathogenesis and treatment of chronic allograft nephropathy. Nat Rev Nephrol. 2009;5(9):513-519. doi:10.1038/nrneph.2009.113
3. Solez K, Colvin RB, Racusen LC, et al. Banff 07 classification of renal allograft pathology: updates and future directions. Am J Transplant. 2008;8(4):753-760. doi:10.1111/j.1600-6143.2008.02159.x
4. Nimmo A, Elyan B, Lakey J, et al. Increased cancer risk in kidney transplant patients in Scotland: a national registry linkage study. Br J Cancer. 2025;133(4):555-563. doi:10.1038/s41416-025-03086-2
5. Oliveras L, Pareja L, Ribes J, et al. Cancer risks in people on dialysis and kidney transplant recipients: a Catalan cohort study, 2003-21. Clin Kidney J. 2025;18(4):sfaf077. doi:10.1093/ckj/sfaf077
6. Wang Y, Lan GB, Peng FH, Xie XB. Cancer risks in recipients of renal transplants: a meta-analysis of cohort studies. Oncotarget. 2017;9(20):15375-15385. doi:10.18632/oncotarget.23841
Prognosis for Kidney Transplantation
Most rejection episodes and other complications occur within 3 to 4 months after transplantation (1); most patients then return to more normal health and activity but must take maintenance doses of immunosuppressants indefinitely.
At 1 year after kidney transplantation, patient and graft survival rates are excellent (patient: 97 to 99%, graft: 95 to 98%) (2).
At 5 years after kidney transplantation, estimated survival rates in the United States are (2):
Living-donor grafts: 93% (patients) and 90% (grafts)
Deceased-donor grafts: 86% (patients) and 81 to 82% (grafts)
International registries report comparable or slightly higher rates (3). Median graft survival is estimated at approximately 19 years for living-donor and 12 years for deceased-donor transplants (4).
The best clinical predictor of prognosis remains:
Serial determination of serum creatinine
In a specific patient, the most recently obtained creatinine levels should be compared with previous levels; a sudden increase in creatinine indicates the need to look for rejection or another problem (eg, vascular compromise, obstruction of the ureter). Ideally, serum creatinine should be normal in all posttransplant patients 4 to 6 weeks after kidney transplantation. The 1-year post-transplantation serum creatinine can be used to the stratify risk of graft failure in recipients of both living and deceased-donor kidneys (5).
Doppler ultrasound measurement of peak systolic and minimal end-diastolic flow, to estimate resistance to flow in renal segmental arteries after transplantation, may help assess prognosis (6).
Prognosis references
1. Nankivell BJ, Borrows RJ, Fung CL, O'Connell PJ, Allen RD, Chapman JR. The natural history of chronic allograft nephropathy. N Engl J Med. 2003;349(24):2326-2333. doi:10.1056/NEJMoa020009
2. Hariharan S, Israni AK, Danovitch G. Long-Term Survival after Kidney Transplantation. N Engl J Med. 2021;385(8):729-743. doi:10.1056/NEJMra2014530
3. Lentine KL, Smith JM, Lyden GR, et al. OPTN/SRTR 2023 Annual Data Report: Kidney. Am J Transplant. 2025;25(2S1):S22-S137. doi:10.1016/j.ajt.2025.01.020
4. Poggio ED, Augustine JJ, Arrigain S, Brennan DC, Schold JD. Long-term kidney transplant graft survival-Making progress when most needed. Am J Transplant. 2021;21(8):2824-2832. doi:10.1111/ajt.16463
5. Mankani MH, Mahmud O, Hafeez MS, et al. Factors Associated With Long-term Kidney Allograft Survival: A Contemporary Analysis of the UNOS Database. Transplant Proc. 2025;57(2):194-207. doi:10.1016/j.transproceed.2025.01.006
6. Naesens M, Heylen L, Lerut E, et al. Intrarenal resistive index after renal transplantation. N Engl J Med. 2013;369(19):1797-1806. doi:10.1056/NEJMoa1301064
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