Getting listed for a kidney transplant isn’t just a medical step-it’s a full-time job. If you’re facing end-stage kidney disease, the thought of a transplant can feel like a lifeline. But the road there is long, complex, and often overwhelming. You’ll need to pass a detailed medical review, prove you can handle life after surgery, and wait-sometimes for years-until a kidney becomes available. And if you’re lucky enough to have someone willing to donate, there’s another whole process just for them. This isn’t a checklist you can speed through. It’s a system built to protect both you and the limited supply of organs. Here’s what actually happens, step by step, based on real protocols used in U.S. transplant centers as of 2025.
How the Evaluation Starts
It usually begins with your nephrologist. When your eGFR drops below 20 mL/min/1.73m², they’ll refer you to a transplant center. That doesn’t mean you’re automatically on the waitlist. First, you need to prove you’re a candidate. The process starts with an intake coordinator who asks basic questions: Do you have insurance? Who will help you after surgery? Can you get to appointments regularly? If you can’t answer these, the center won’t move forward. They’ve seen too many patients drop out after months of testing because they didn’t have a ride to dialysis, or couldn’t afford the co-pays. You’ll get a thick packet of forms to fill out within 14 days. This isn’t bureaucracy for the sake of it. It’s how they screen for red flags: depression, substance use, unstable housing, or a history of missing medications. One patient in Texas missed his evaluation by three weeks because he thought the forms were optional. He lost his spot on the list. Before any blood tests or scans, you must attend a transplant education class. No exceptions. You’ll learn about immunosuppressants-how they work, what they cost, and why you can’t skip a single dose. Centers require you to demonstrate you understand this. If you can’t explain why you can’t take ibuprofen after transplant, you won’t be listed. That’s not harsh-it’s survival. One study found patients who couldn’t describe their meds had a 40% higher chance of graft failure in the first year.What Tests You’ll Go Through
The medical tests are extensive. You’ll need blood work for your kidney and liver function, blood type, and viral screens for HIV, hepatitis B and C. The HIV test used today isn’t the old one-it’s a fourth-generation test that catches infections within weeks, not months. Your heart gets a full check, too. You’ll need an echocardiogram to make sure your ejection fraction is at least 40%, a stress test to prove you can handle 5 metabolic equivalents (that’s walking up two flights of stairs without stopping), and a chest X-ray. If you’re over 50, men need a PSA test. Women need a mammogram and Pap smear. It’s not optional. Centers have to follow strict federal rules to qualify for Medicare reimbursement. There are also hidden cutoffs. Hemoglobin must be above 10 g/dL. Platelets above 100,000/μL. Albumin above 3.5 g/dL. If your albumin is low, you’ll be asked to see a dietitian first. If your blood pressure won’t stabilize, you’ll be referred to a specialist. One patient in California spent six weeks just getting his BP under control before they’d even look at his heart scan. You’ll also get HLA typing and PRA testing. These check how likely your body is to reject a kidney. If your PRA is high-meaning you’ve built up antibodies from past transplants, pregnancies, or blood transfusions-you’re harder to match. That doesn’t disqualify you, but it means you’ll wait longer. In 2024, centers started using cPRA (calculated PRA) to prioritize patients with the highest levels. Someone with a cPRA of 98% gets top priority on the list, even if they’ve been waiting less time than others.The Psychosocial Review
This is where most people get tripped up-not because of their health, but because of their life. A transplant social worker will sit down with you and ask hard questions: Who will drive you to appointments? Can you afford $3,500 in out-of-pocket costs for meds in the first year? Do you have someone to call at 3 a.m. if you feel sick? Are you willing to take 10 pills a day, forever? They’re not judging you. They’re trying to predict who will stick with the plan. Psychosocial failure is now the #1 reason people don’t get listed. A 2024 study found it accounts for 32% of rejections-more than heart disease or obesity. One man in Florida was turned down because he said he’d “just stop the pills if he felt fine.” He didn’t understand that stopping immunosuppressants could kill him in days. Another woman was deferred because she had no one to help her after surgery. She lived alone and didn’t drive. The center gave her six months to find a ride and come back. She did. She got her transplant.Insurance and Costs
Medicare covers 80% of transplant costs under Part B. But you’ll still pay 20%-and that’s before drugs. Prescription drugs after transplant cost an average of $32,000 a year. Most centers require proof you can pay for them. Private insurance covers 70-90%, but deductibles average $4,550 a year. Medicaid patients wait 37 days longer on average just to get through evaluation because of paperwork delays. Insurance denials are the second biggest cause of delays. A patient in Ohio had to fight for 11 weeks to get approval for a cardiac stress test. The insurer said it wasn’t “medically necessary.” He had to get a letter from his nephrologist, then his cardiologist, then his transplant coordinator. He finally got it approved on the 12th try. That’s not rare. One in four Medicaid patients gets denied at least one test.
Getting on the Waitlist
Once all your tests are done, your case goes to a transplant selection committee. This group includes a surgeon, nephrologist, social worker, psychiatrist, and coordinator. They meet weekly. You’ll get a decision within 72 hours. If you’re approved, you’re listed. If not, you’ll get a letter explaining why. You can appeal. But most rejections are final. As of January 2025, over 102,000 people are on the kidney waitlist in the U.S. The average wait for a deceased donor kidney is 3.6 years. But that number means nothing if you’re not ready when a kidney becomes available. If you’ve been slow to complete your evaluation, you’ll miss the chance. Centers prioritize those who’ve finished everything on time. A 2023 SRTR report showed patients who finished evaluation within 90 days were 22.7% more likely to get a transplant within two years.Living Donors: A Faster Path
About 39% of kidney transplants in 2024 came from living donors. That’s because kidneys are the only organ you can live without one of. A living donor transplant cuts your wait time to weeks instead of years. But it’s not easy. The donor must be healthy, blood type compatible, and willing to undergo surgery. They go through their own evaluation-same blood tests, heart scans, mental health check. But it’s faster now. Leading centers use “rapid crossmatch” protocols that cut donor evaluation from 6-8 weeks to just 2-3. The Kidney Paired Donation Program helps when the donor isn’t compatible with you. You swap with another pair. Your donor gives to someone else. Someone else’s donor gives to you. In 2023, this program helped 1,872 people get transplants. Donors don’t pay for their evaluation. But they lose wages. Some centers offer stipends. Most don’t. The National Kidney Foundation says 42% of donors take unpaid leave. That’s why financial counseling is part of donor evaluation too.What Happens After You’re Listed
You’re not done. You’ll need to keep your health stable. Gain weight? Lose it. Start smoking? You’ll be removed from the list. Miss a dialysis session? You’ll be put on probation. You’ll need to update your insurance info every six months. You’ll get called at any time-day or night-if a kidney becomes available. That’s why you need to keep your phone charged and your emergency contact updated. You’ll also need to stay connected to your transplant coordinator. They manage 45-60 patients at once. If you don’t reply to their messages, you’ll be forgotten. One patient in Arizona got a call for a kidney but didn’t answer because he was at work. The kidney went to someone else. He had to wait another 14 months.
Why Some People Don’t Make It
The top five reasons people are turned down for transplant:- Active cancer (14.2%)
- Severe heart disease (11.8%)
- Uncontrolled infection (9.3%)
- Severe obesity (BMI over 40, 8.7%)
- History of not taking meds (7.9%)
What You Can Do Right Now
- Get all your medical records from the last five years. Dialysis logs, lab results, hospital discharge summaries. Bring them to your first appointment. - Pick one person to be your support person. They come with you to every visit. They take notes. They ask questions you forget. - Call your insurance company. Ask: “What’s covered under transplant evaluation? What’s not? What’s my deductible?” - Start tracking your meds. If you’ve missed doses before, write down why. Be honest with your social worker. - If you have a friend or family member who wants to donate, tell them to contact the transplant center directly. They can start their evaluation even before you’re listed. - Don’t wait. The sooner you start, the sooner you finish. Delaying your evaluation by even 30 days cuts your chances of getting a transplant in the next two years by nearly 20%.FAQ
Can I be listed for a transplant if I have diabetes?
Yes, but your diabetes must be well-controlled. If your HbA1c is above 8%, you’ll need to see an endocrinologist and show you can manage your blood sugar before being listed. Poor control increases infection risk and can damage the new kidney.
How long does the transplant evaluation take?
It typically takes 12 to 16 weeks for deceased donor candidates and 8 to 12 weeks for those with a living donor. High-volume centers finish faster-up to 23% quicker. Delays happen when tests are missed, insurance is slow, or patients don’t show up.
Can I be on the waitlist if I’m over 70?
Age alone doesn’t disqualify you. Centers look at biological age, not calendar age. If you’re healthy, active, and have strong support, you can be listed. In 2024, over 18% of kidney transplants went to patients over 70.
What if I can’t afford the post-transplant meds?
You must show a plan. Most centers require proof of coverage through Medicare Part D, private insurance, or patient assistance programs. The American Kidney Fund and National Transplant Assistance Fund offer grants. Don’t wait until you’re listed-start applying now.
Can I get a transplant if I’ve had cancer?
It depends on the type and timing. Most centers require five years of remission for solid tumors. Skin cancers like basal cell carcinoma are often okay after treatment. If you’ve had lymphoma or leukemia, you’ll need special review. Never hide your history-it will come out in testing.
Do I need to be sober to qualify?
Yes. Active alcohol or drug use disqualifies you. But if you’ve been sober for at least six months and are in a recovery program, you can be considered. You’ll need letters from your counselor and proof of attendance. Relapse after transplant is dangerous and often leads to graft loss.
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