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

Getting listed for a kidney transplant isn’t something that happens overnight. It’s a long, detailed process that starts long before you even see the operating room. If you’re waiting for a new kidney-whether from a deceased donor or a living one-you need to understand what comes before the surgery. The evaluation, the waitlist, and finding a living donor are three separate but deeply connected parts of the journey. And getting through them successfully can make all the difference in how long you wait and how well you recover.

What Happens During the Transplant Evaluation?

The evaluation is your first real step toward a transplant. It’s not just a checkup. It’s a full medical and personal audit to make sure you’re physically and emotionally ready for the procedure and the lifelong care that follows. Every transplant center in the U.S. follows strict national guidelines set by the Organ Procurement and Transplantation Network (OPTN), and most require you to complete this process within 12 weeks of your first appointment.

You’ll start with a referral from your nephrologist, usually when your kidney function drops below an eGFR of 20. From there, you’ll be assigned a transplant coordinator who becomes your main point of contact. They’ll schedule everything: blood tests, imaging, specialist visits. You’ll need to bring your complete medical history-ideally, five years of records, including dialysis logs if you’ve had them. Missing appointments is one of the biggest reasons evaluations get delayed. About 18% of candidates fall behind simply because they miss a test or a meeting.

Medically, you’ll go through a long list of tests. Blood type and tissue matching (HLA typing) are basic. You’ll be screened for HIV, hepatitis B and C, and other infections using the latest CDC-recommended tests. Your heart gets checked too: an echocardiogram to measure how well your heart pumps, a stress test to see if you can handle physical exertion (you need to hit at least 5 metabolic equivalents), and an EKG. Liver and kidney function tests, including albumin and platelet counts, must be in normal range. For men over 50, a PSA test is required. Women need regular mammograms and Pap smears.

But the medical side is only half the story. You’ll also meet with a transplant social worker and a psychologist. They’ll ask hard questions: Who will help you after surgery? Can you get to your follow-up appointments? Do you have money saved for medications? Northwestern Medicine, for example, requires proof you have at least $3,500 in liquid assets to cover your first year of anti-rejection drugs. They’re not trying to be harsh-they’re trying to prevent you from stopping your meds later because you can’t afford them. That’s the #1 reason transplants fail after the first year.

The whole process takes 15 to 25 appointments and usually 8 to 16 weeks. High-volume centers finish faster-sometimes 23% quicker-because they’ve streamlined scheduling. If you’re lucky, your coordinator might group your tests so you don’t have to come in 10 separate times. One patient on Reddit said their coordinator turned 12 weeks of visits into six by coordinating everything in blocks. That kind of support matters.

How Do You Get on the Waitlist?

Once all your tests are done, your case goes to the transplant selection committee. This group includes a surgeon, nephrologist, social worker, psychiatrist, and coordinator. They meet weekly. Their job isn’t just to approve you-they’re also there to protect you. If they see you’re not ready, they’ll tell you why and what you need to fix before reapplying.

The committee looks at three things: medical suitability, psychosocial readiness, and fairness. Medical reasons for denial include active cancer, uncontrolled infection, severe heart disease, or a BMI over 40. But surprisingly, psychosocial issues cause more failures than medical ones. About 32% of candidates are turned down because of concerns about support systems, substance use, or inability to follow complex medication schedules. That’s more than heart problems or obesity.

Insurance is another major hurdle. Medicare covers 80% of transplant costs, but you still need to pay your deductible-averaging $4,550 a year. Private insurance usually covers 70-90%, but many plans require pre-authorization for every test. One in four Medicaid patients face delays because their insurance denies coverage for a specific test. That can add weeks, even months, to your timeline. The National Kidney Foundation says 28.7% of all evaluation delays come from insurance issues.

If you’re approved, you’re officially listed. But being on the list doesn’t mean you’ll get a kidney soon. As of January 2024, over 102,000 people in the U.S. were waiting for a kidney. The average wait time? 3.6 years. And it’s not first-come, first-served. Your wait time depends on your blood type, tissue match, and how sensitized your immune system is. People with high levels of antibodies (cPRA over 98%) get priority because finding a match is so hard.

What Is a Living Donor, and How Does It Work?

The best way to shorten your wait? A living donor. About 39% of all kidney transplants in 2023 came from living donors-mostly family members, friends, or even strangers. The reason? Kidneys are the only organ you can live without one of. And living donor transplants have higher success rates: 96.3% of these kidneys still work after one year, compared to 94.1% for deceased donor kidneys.

Finding a living donor isn’t just about asking someone. The donor has to go through their own evaluation. They need to be healthy, free of diabetes or high blood pressure, and have normal kidney function. Their blood type must match yours-or be compatible. Even if they’re not a direct match, they might still help through the Kidney Paired Donation Program. This program swaps donors between pairs. For example, if your sister wants to donate but her blood type doesn’t match yours, she can donate to someone else whose donor matches you. In 2023, this program helped 1,872 people get transplants.

The donor evaluation is faster now. Leading centers use “rapid crossmatch” protocols that cut the process from 6-8 weeks down to just 2-3. Donors still need blood tests, imaging, psychological screening, and a full physical. But they’re not evaluated for “worthiness.” They’re evaluated for safety. If they’re healthy enough to donate, they’re eligible.

Many donors worry about costs. But by law, the recipient’s insurance covers all donor-related medical expenses. Some organizations also help with travel and lost wages. Still, the emotional weight can be heavy. One donor told me, “I didn’t realize how much guilt I’d feel if something went wrong.” That’s why counseling is mandatory for donors too.

What Happens If You Don’t Get Approved?

Not everyone makes it to the waitlist. About 12% of evaluations are canceled because testing isn’t completed. Others are denied for medical or psychosocial reasons. But denial isn’t the end. Many people get re-evaluated after fixing the issue-losing weight, quitting smoking, getting mental health support.

If you’re denied because of financial concerns, don’t give up. Talk to your transplant center’s financial counselor. There are programs that help with medication costs, transportation, and even housing near the hospital. The American Kidney Fund and National Transplant Foundation offer grants and support networks.

If you’re denied for mental health reasons, work with a therapist. Many centers will re-evaluate you after six months of consistent care. The goal isn’t to turn you away-it’s to make sure you’re set up to succeed.

What Can You Do to Speed Things Up?

There are things you can control. First, stay organized. Keep a notebook or digital folder with all your test results, appointment dates, and insurance communications. Use your patient portal. Check it daily. If a test is missing, call your coordinator right away.

Second, bring a support person to every appointment. Not just for moral support. They’ll remember things you miss. They can ask questions you didn’t think of. And if you’re feeling overwhelmed, they can speak up.

Third, start talking to your family and friends about donation. Don’t wait until you’re desperate. Say, “I’m going to be evaluated for a transplant. If you’re healthy and willing, I’d like to know if you’d consider being tested.” Most people don’t think they’re qualified. They’re often surprised to find out they are.

And finally, don’t delay. Research shows that people who finish evaluation within 90 days of their first referral have an 11.3% higher chance of surviving five years after transplant. The sooner you start, the sooner you can move forward.

What’s New in Kidney Transplantation?

The field is changing fast. In 2023, over 200 HIV-positive patients received kidneys from other HIV-positive donors-something that was impossible just a decade ago. The HOPE Act opened the door. Now, people with well-controlled HIV can be both donors and recipients.

New allocation rules now give priority to patients with the highest antibody levels, making it easier for those who’ve had previous transplants or pregnancies to find matches. And by 2026, new federal rules are expected to reduce the number of people who abandon their evaluation because they can’t afford it.

But challenges remain. Black patients still wait longer than White patients-even after adjusting for medical need. Centers that use standardized evaluation pathways have cut that gap in half. If your center doesn’t have one, ask if they’re planning to implement one. Equity matters.

Final Thoughts

Preparing for a kidney transplant is exhausting. It’s expensive. It’s emotional. But it’s also the most effective treatment for end-stage kidney disease. Every step-every blood draw, every appointment, every conversation about money and mental health-is part of building a future where you’re not tied to a machine, where you can sleep through the night, where you can walk without being out of breath.

You’re not just waiting for a kidney. You’re preparing for a second chance. And the more you understand the process, the more power you have to move through it.

Next steps: Talk to your nephrologist about getting referred to a transplant center. Ask for a list of nearby centers and their average evaluation times. Start gathering your medical records. And don’t be afraid to ask your circle: “Would you consider being tested as a living donor?” The right person might be closer than you think.