End-stage kidney disease (ESKD) is the most advanced stage of chronic kidney disease, when the kidneys can no longer perform enough of their essential functions to keep the body healthy. At this stage, kidney replacement therapy is needed, usually in the form of dialysis or a kidney transplant.
A kidney transplant replaces failed kidney function with a healthy kidney from a living or deceased donor. For eligible patients, transplantation can offer an alternative to long-term dialysis and may provide greater freedom in daily life.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
However, reaching ESKD does not mean that every patient can immediately receive a transplant. A detailed medical evaluation is required to determine whether transplantation is appropriate and to identify the most suitable treatment pathway. Learn more about the procedure in our Kidney Transplant Surgery guide.
What Does End-Stage Kidney Disease Mean?
End-stage kidney disease, also called kidney failure, occurs when kidney function has declined to a level at which the kidneys can no longer adequately remove waste, regulate fluids and electrolytes, and maintain the body's internal balance.
Stage G5 chronic kidney disease is generally defined as an eGFR below 15 mL/min/1.73 m² that persists for at least three months, or a person being treated with dialysis. This measurement helps describe the severity of kidney disease, but treatment decisions are not based on the eGFR number alone.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
As kidney function declines, waste products and excess fluid can accumulate in the body. Other complications may also develop, including anaemia, disturbances in potassium and acid levels, bone and mineral problems, high blood pressure, and cardiovascular complications.
Why Does ESKD Lead to the Need for a Transplant?
When the kidneys have permanently lost most of their function, medicines and lifestyle changes alone cannot replace the work performed by healthy kidneys.
Dialysis can remove some waste products and excess fluid and help maintain the body's chemical balance. A transplant, on the other hand, provides a functioning kidney that can perform many of the functions of a healthy kidney. This is why transplantation is considered one of the main forms of kidney replacement therapy for people with kidney failure.
Kidney Transplant or Dialysis?
For a person with ESKD who is medically suitable for transplantation, the choice is not necessarily a simple decision between two treatments that are completely separate. Dialysis may be needed while a patient is being evaluated or while waiting for a suitable donor kidney. A kidney transplant can be performed:
- Before dialysis begins — known as a preemptive kidney transplant.
- After dialysis has started — which is common when a suitable kidney is not immediately available.
Being on dialysis does not mean that transplantation is no longer possible. Many people receive a kidney transplant after spending time on dialysis.
Why Might Transplantation Be Considered for ESKD?
For appropriately selected patients, a successful kidney transplant can provide functioning kidney replacement without the need for ongoing dialysis. Compared with remaining on dialysis, transplantation may offer:
- Greater freedom from regular dialysis sessions
- Fewer dietary and fluid restrictions in many patients
- Improved quality of life
- Greater flexibility for work, travel, and everyday activities
- Longer survival for many appropriately selected patients
These potential benefits need to be considered alongside the risks of major surgery, the possibility of rejection, complications associated with transplantation, and the need for lifelong anti-rejection medicines.
Can a Person With ESKD Receive a Transplant Before Dialysis?
Yes. When kidney function is declining toward kidney failure, transplant evaluation can begin before dialysis is required. A transplant performed before dialysis is known as a preemptive kidney transplant. This approach is particularly relevant when a suitable living donor is available and the transplant can be planned in time.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
Starting the evaluation early gives the transplant team time to assess the patient's health, complete compatibility testing, identify a potential living donor if applicable, and address medical issues that could affect transplantation.
Not every person with ESKD will be able to receive a preemptive transplant. The timing of kidney failure, medical suitability, donor availability, and the transplant evaluation process all influence whether this is possible.
What Happens When Someone With ESKD Is Referred for a Transplant?
The first step is a transplant evaluation. This is much more than a single test. It is a comprehensive assessment designed to determine whether transplantation is medically appropriate and whether the patient can safely undergo surgery and manage the treatment required afterward.
The evaluation may include:
- Review of kidney disease and medical history
- Blood and urine investigations
- Blood-group and tissue-compatibility testing
- Antibody testing
- Heart and lung assessment
- Screening for infections
- Age- and risk-appropriate cancer screening
- Assessment of blood vessels and other anatomical factors
What If the Patient Has a Living Donor?
A living donor may be a relative, spouse, friend, or another eligible person who is willing to donate a kidney. The donor must undergo a separate evaluation to ensure that donation is medically safe and that the kidney is suitable for the recipient.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
One of the important advantages of having a suitable living donor is that the transplant can potentially be planned rather than waiting for an organ to become available through a deceased-donor system.
Compatibility is assessed through blood-group testing, tissue typing, antibody testing, and other investigations. If a potential donor is not directly compatible, alternative pathways may sometimes be available depending on the transplant programme.
Does Everyone With ESKD Qualify for a Kidney Transplant?
No. Kidney failure establishes the need for kidney replacement therapy, but it does not automatically establish eligibility for transplantation. The transplant team needs to determine whether the patient is healthy enough to undergo major surgery and whether the expected benefits of transplantation outweigh the risks.
Conditions that may require careful assessment or treatment before transplantation can include significant heart or blood-vessel disease, active infections, certain cancers, severe uncontrolled medical conditions, or other factors that could make transplantation unsafe.
Having another medical condition does not automatically mean that transplantation is impossible. In some cases, the condition can be treated or stabilised before the transplant process continues.
What Happens After a Kidney Transplant?
A transplant does not eliminate the need for medical care. The recipient must take anti-rejection medicines for as long as the transplanted kidney is functioning, along with regular follow-up and laboratory monitoring.
The transplant team monitors kidney function and looks for complications such as rejection, infection, medication-related problems, and other conditions that can affect the transplanted kidney or the recipient's health.
A transplant is therefore best understood as a long-term treatment for kidney failure rather than a one-time operation that ends the need for ongoing care.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
The Bottom Line
End-stage kidney disease means that kidney function has declined to the point where kidney replacement therapy is needed. For patients who are medically suitable, a kidney transplant can provide functioning kidney replacement and remove the need for ongoing dialysis after a successful transplant.
The transplant journey can begin before dialysis. Early evaluation may allow a suitable patient to receive a preemptive transplant, particularly when a living donor is available. When transplantation cannot happen immediately, dialysis can provide kidney replacement therapy while the patient continues through evaluation or waits for a suitable donor.
Ultimately, the decision to pursue transplantation depends on much more than the diagnosis of ESKD. Kidney function, overall health, transplant suitability, donor availability, and the patient's ability to manage lifelong post-transplant treatment all need to be considered.
