A kidney transplant is a surgical procedure to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer function properly. Kidney transplantation is typically the treatment of choice for most people with end-stage kidney disease who need dialysis. However, not everyone with kidney failure qualifies for a transplant. There are several reasons why a person may not be eligible to receive a donor kidney.
Medical Conditions That Can Disqualify a Kidney Transplant
Uncontrolled Hypertension
High blood pressure, also known as hypertension, can damage the blood vessels in the new kidney. Potential recipients with severe hypertension that is difficult to control with medication may not be good candidates for transplantation. Doctors will want to see that your hypertension is well-managed before approving you for a kidney transplant.
Heart Disease
A history of heart disease like heart failure, previous heart attack, and blocked arteries increases the risks associated with major surgery. A transplant candidate must be strong enough to withstand the rigors of surgery. Severe heart disease could disqualify you from a transplant.
Obesity
Obesity makes surgery more technically challenging. Overweight transplant recipients also have an increased risk of surgical complications, infections, and diabetes after the transplant. Candidates with a BMI over 40 may need to lose weight before being activated on the transplant waitlist.
Cancer
Certain cancers are considered a contraindication to transplantation because the immunosuppression medication required after transplant increases the risk of recurrence or new malignancies. Exceptions may be made for certain cancers that have been fully treated and in remission for several years.
Chronic Lung Disease
Serious lung conditions like COPD, pulmonary fibrosis, and cystic fibrosis can increase the risks associated with anesthesia and surgery. Severe chronic lung disease often precludes candidates from kidney transplantation.
Vascular Disease
Diseases affecting the arteries and veins, like peripheral vascular disease, can reduce accessibility for the surgical procedure and increase complications after transplant. Severe vascular disease involving the abdomen can make kidney transplant too risky.
Active Infections
Any acute, uncontrolled infection raises concerns about subjecting the patient to the immunosuppression required after a kidney transplant. Certain chronic infections like HIV, hepatitis B/C may also disqualify candidates until appropriately treated and stabilized.
Psychiatric Illness
Active major psychiatric disease like schizophrenia, bipolar disorder, or substance abuse can affect a patient’s ability to take medications properly and comply with post-transplant care. These conditions need optimization before getting activated on the waitlist.
Dementia
Individuals with advanced dementia or Alzheimer’s disease often lack the cognitive ability to understand and consent to the procedure. They may also struggle to adhere to complex post-transplant medication regimens.
Age Limitations for Kidney Transplant
Most transplant programs accept adult candidates between the ages of 18 and 75. Patients over 75 face higher surgical risks and decreased long-term survival rates. Very young pediatric patients also pose technical challenges for transplantation and lifelong immunosuppression risks.
Minimum Age Requirements
Children under five years old rarely receive adult-sized kidney transplants except in exceptional circumstances. The kidneys must reach a certain size to properly fit within an adult’s pelvis. Very young children may need multiple transplants as they grow.
Maximum Age Limitations
While some programs set the cutoff at 75 years, policies are evolving. Some centers now individually evaluate elderly patients over 75 if they are otherwise strong transplant candidates. Candidates over 75 must consider surgical risks, life expectancy, quality of life gains, and longevity of the transplanted kidney.
Contraindications Based on Lifestyle Factors
Certain lifestyle factors that could impact transplant success may also prevent candidates from being waitlisted until these behaviors change.
Alcohol and Substance Abuse
Active alcoholism and illicit substance abuse are contraindications due to non-compliance concerns. Most programs require at least 6 months of sobriety before activating a candidate on the kidney transplant waitlist.
Non-Adherence
If a patient has shown repeated non-adherence to dialysis schedules and medical instructions, the transplant team may have concerns about compliance post-transplant. Individuals must demonstrate responsibility before getting approved.
Inability to Pay for Medications
Transplant recipients must take immunosuppressant drugs daily to prevent organ rejection. These medications are expensive. Transplant programs need assurance that patients can pay for these lifelong drugs.
Lack of Caregiver Support
Transplant recipients need assistance immediately after surgery and help managing medications long-term. Living alone without adequate family or social support can disqualify candidates.
Smoking
Smoking cigarettes greatly increases the risk of infections and poor wound healing after any surgery. Most programs require candidates to quit smoking for at least 6 months before transplant.
High Risk for Poor Outcomes
In certain situations, a comprehensive evaluation may determine that the risks of a kidney transplant outweigh the potential benefits for a given patient. Even if technically possible, transplantation may be inadvisable.
Multiple Health Conditions
While one or two health issues may be manageable, a candidate with multiple comorbidities like advanced diabetes, heart disease, obesity and hypertension may be considered too high risk.
Prior Major Surgery Complications
If an individual experienced severe complications from a previous major surgery, doctors may advise against transplantation due to concerns about safety.
Rapidly Deteriorating Health
Candidates who are cachectic and deteriorating rapidly usually receive recommendation against transplant. Severe malnutrition makes recovery very difficult.
Metastatic Cancer
Widespread metastatic cancer has very low transplant survival rates. Remaining life expectancy without transplant must be considered.
Advanced Age
While every patient is unique, elderly individuals over 75-80 years old often have lower transplant survival rates and increased risks. Quality of life benefits must be weighed.
Financial Barriers to Transplant
The costly evaluation process and lifelong care makes transplantation impossible for some patients without adequate financial resources or insurance coverage.
Inability to Afford Evaluation
The extensive medical testing required before wait-listing can cost tens of thousands of dollars without insurance. Many cannot pursue transplantation due to financial limitations.
Lack of Medical Insurance Coverage
Medicare covers transplantation for most patients. Medicaid and other insurance plans may also pay. Without coverage, few individuals can afford surgery and lifelong immunosuppression.
Inadequate Income
Even with insurance, copays for anti-rejection drugs can be hundreds per month. Additionally, transplant recipients often cannot work for months after surgery. A limited income may make transplant unrealistic.
Shortage of Available Kidneys
Due to the severe shortage of available kidneys for transplantation, some patients die while on the national transplant waiting list. Others become too sick to undergo surgery. Expanding donation is critical to provide access for all patients in need.
Long Wait Times
Depending on blood type, candidates can wait over 5 years for a deceased donor kidney. Many run out of time on dialysis before reaching the top of the list. The wait is a contraindication for the most urgent cases.
Inadequate Living Donors
Living donor transplants have faster wait times and better outcomes, but require a volunteer. Some patients lack willing or medically eligible living donors within their family and support networks.
High PRA Levels
A patient’s panel reactive antibody (PRA) level indicates the percentage of the population whose tissue would be incompatible for them. Individuals with very high PRA levels due to previous transplants or pregnancies may wait many years for a viable donor match.
Legal and Ethical Challenges
There are also legal and ethical considerations that come into play regarding which individuals can receive scarce lifesaving transplants with so many people in need.
Incarceration
U.S. policies generally prohibit prisoners from accessing organ transplantation during incarceration due to ethical debates about allocation justice.
Undocumented Immigration Status
Undocumented immigrants face barriers to transplantation since they may have no financial resources, insurance coverage, or government assistance programs to pay for the procedure and anti-rejection medications.
Unresolved Legal Issues
Outstanding felony legal charges, parole or probation violations may need resolution before activation on the waitlist based on program-specific policies
Alternatives to Kidney Transplant
For patients who do not qualify for a kidney transplant or remain on the waiting list, there are some alternatives for treating kidney failure.
Peritoneal Dialysis
Peritoneal dialysis uses the lining of the abdomen to filter waste products from the blood. The abdomen is slowly filled with dialysate fluid which absorbs toxins and drains out. The process can be done at home.
Hemodialysis
Most people on dialysis undergo hemodialysis. Blood is pumped through an external machine that filters out wastes. Hemodialysis requires travel to a dialysis clinic three days per week.
Conservative Care
Some patients choose to forgo dialysis and manage kidney failure conservatively through diet, medications, and symptom control. This option avoids the risks and burdens of dialysis.
Conclusion
Kidney transplantation can prolong life and improve quality of life for those with end-stage renal disease. However, the procedure involves significant medical risks and lifestyle adjustments. Transplant centers must determine if patients qualify medically, psychologically and financially to tolerate surgery, comply with follow up care, and experience good outcomes. Although transplantation is not readily available or advisable for every patient with kidney failure, survival can often still be extended through dialysis treatment until transplant becomes feasible or the end of life draws near. With careful evaluation and selection criteria, kidney transplantation provides enormous benefits for thousands of individuals each year. Continued public education about kidney donation and advances in treatment options remain essential to maximize access for all people living with chronic kidney disease.