Clinical UM Guideline

This document addresses kidney transplantation, involving the removal of the kidney from a deceased or living donor with the implantation into a single recipient.

Note: Please see the following related transplant documents for additional information:

• TRANS.00008 Liver Transplantation
• TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Note: Members must meet the clinical indications as well as the general individual selection criteria for the transplantation to be considered medically necessary.

Medically Necessary:

Kidney transplantation from a deceased or a living donor is considered medically necessary for selected individuals with end stage renal disease*. The clinical indications leading to end stage renal disease include, but are not limited to, one of the conditions listed below.

*Note: See Definition section for further information on end stage renal disease.

Clinical Indications:

1. Congenital Disorders
   1. Aplasia
   2. Hypoplasia
   3. Horseshoe Kidney
2. Toxic Nephropathies
   1. Lead nephropathy
   2. Analgesic nephropathy
   3. Metabolic Disorders
   4. Hyperoxaluria
   5. Nephrocalcinosis
   6. Gout
   7. Amyloidosis
   8. Cystinosis
3. Hereditary Nephropathies
   1. Alport's syndrome
   2. Polycystic kidney disease
   3. Medullary cystic disease
4. Irreversible Acute Renal Failure
   1. Cortical necrosis
   2. Hemolytic uremic syndrome
   3. Acute and subacute glomerulonephritis
   4. Anaphylactoid purpura (Henoch-Schonlein)
5. Irreversible Chronic Renal Failure
   1. Chronic pyelonephritis
   2. Diabetic nephropathy
   3. Chronic glomerulonephritis
   4. Hypertensive nephrosclerosis
   5. Goodpasture's disease
   6. Hypocomplementemic nephritis
   7. Steroid-resistant nephrotic syndrome
   8. Toxic nephropathy (including nephropathy related to cyclosporine/tacrolimus toxicity)
   9. Chronic allograft nephropathy (that is, chronic rejection)
6. Tumors Requiring Nephrectomy
   1. Renal carcinoma
   2. Wilms’ tumor
   3. Tuberous sclerosis
7. Renal Vascular Diseases
   1. Renal artery occlusion
   2. Renal vein thrombosis
8. Obstructive Uropathy
   1. Acquired
   2. Congenital
9. Trauma requiring nephrectomy
10. Other Indications
    1. Scleroderma
    2. Polyarteritis (periarteritis nodosa)
    3. Multiple Myeloma
    4. Lupus Erythematosus
    5. Macroglobulinemia
    6. Wegner's Disease
    7. Etiology unknown (documented chronic renal failure of at least 6-8 weeks duration)

Retransplantation

Repeat transplant due to acute or chronic graft failure is considered medically necessary.

Simultaneous Liver Kidney Transplantation

Kidney transplant as part of a simultaneous liver kidney (SLK) transplantation is considered medically necessary when criteria for liver transplantation are met and when one of the following are met:

1. The individual has acute renal failure secondary to either hepatorenal syndrome or acute kidney injury; either of which have required at least 6 weeks of dialysis therapy; or
2. The individual has chronic kidney disease with a measured creatinine clearance or an estimated glomerular filtration rate (eGFR) of less than or equal to 30 mL/min; or
3. The individual has prolonged acute kidney failure or kidney failure of unknown cause and a renal biopsy showing fixed renal damage.

Not Medically Necessary:

Kidney transplantation for conditions other than end stage renal disease is considered not medically necessary.

Kidney transplantation as part of a simultaneous liver kidney (SLK) transplant is considered not medically necessary, if one of the above SLK criteria is not met.

Note: For multi-organ transplant requests, criteria must be met for each organ requested. In those situations, an individual may present with a concurrent medical condition which may be considered an exclusion or a comorbidity that would preclude a successful outcome, but would be treated with the additional organ transplant. Such cases will be reviewed on an individual basis for coverage determination to assess the member’s candidacy for transplantation.

General Individual Selection Criteria

In addition to having one of the clinical indications above, the member must not have a contraindication as defined by the American Society of Transplantation in Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation (2001) listed below.*

Absolute Contraindications- for Transplant Recipients include, but are not limited to, the following:

1. Metastatic cancer
2. Ongoing or recurring infections that are not effectively treated
3. Serious cardiac or other ongoing insufficiencies that create an inability to tolerate transplant surgery
4. Serious conditions that are unlikely to be improved by transplantation as life expectancy can be finitely measured
5. Demonstrated patient noncompliance, which places the organ at risk by not adhering to medical recommendations
6. Potential complications from immunosuppressive medications are unacceptable to the patient
7. Acquired immune deficiency syndrome (AIDS) (diagnosis based on Centers for Disease Control and Prevention [CDC] definition of CD4 count less than 200 cells/mm³) unless the following are noted:
   1. CD4 count greater than 200 cells/mm³ for greater than 6 months
   2. HIV-1 RNA undetectable
   3. On stable anti-retroviral therapy greater than 3 months
   4. No other complications from AIDS (for example, opportunistic infection, including aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections, Kaposi’s sarcoma or other neoplasm)
   5. Meeting all other criteria for kidney transplantation

*Steinman T, Becker BN, Frost AE,, et al. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation. 2001; 71(9):1189-1204.

This document describes clinical studies and expert recommendations, and explains whether kidney transplantation services are appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

A kidney is an internal organ in the body that helps remove waste and excess fluid from the body. A kidney transplant is a surgery where a healthy kidney from a living or deceased donor is placed into someone whose kidneys no longer work. This is typically done when a person has end-stage kidney disease, which means their kidneys have failed. A transplant may come from a living donor, like a family member or friend, or from someone who has died. The donated kidney is usually placed in the lower belly area. The new kidney is connected to blood vessels and the bladder to help it work properly. In some cases, people with both kidney and liver disease may need a liver and kidney transplant at the same time. Each transplant has risks and benefits, and certain conditions must be met to be considered appropriate for this surgery.

What the Studies Show

Studies have shown that kidney transplantation is generally safe and effective for people with kidney failure. About 35.5 million people in the U.S. have chronic kidney disease, and many will eventually need treatment for kidney failure. In 2025, more than 94,000 people were on the waitlist for a kidney transplant. In that same year, nearly 26,000 kidney transplants were done. Survival rates after transplant are high, with more than 97% of people alive after 1 year. For those with liver and kidney failure, doctors consider several signs to decide if a combined liver-kidney transplant is needed. These include how long the person has needed dialysis, test results showing kidney damage, or low kidney function. Expert groups have also shared guidelines to help decide who is a good candidate for transplant and who should wait until other health issues are treated.

When is Kidney Transplantation Clinically Appropriate?

Kidney transplantation (from a living or deceased donor) may be appropriate in these situations:

• The person has end-stage kidney disease caused by one of the following:
  • Congenital kidney problems (like kidney underdevelopment or fused kidneys)
  • Toxic kidney damage (such as from lead or pain medicines)
  • Metabolic issues (like gout or amyloidosis)
  • Inherited conditions (such as Alport syndrome or polycystic kidney disease)
  • Severe short- or long-term kidney failure
  • Tumors needing kidney removal
  • Kidney blood vessel problems
  • Blockages in the urinary system
  • Kidney loss from injury
  • Other diseases (such as lupus, scleroderma, or unknown causes lasting over 6-8 weeks)
• The person needs a repeat transplant due to graft failure
• The person needs a combined liver-kidney transplant and meets liver transplant criteria, and one of the following:
  • Has had dialysis for at least 6 weeks due to liver-related or acute kidney failure
  • Has long-term kidney disease with low kidney function (measured creatinine clearance or estimated glomerular filtration rate (eGFR)less than or equal to 30 mL/min)
  • Has kidney damage proven by biopsy

When is this Not Clinically Appropriate?

Kidney transplantation is not appropriate in these cases:

• The person does not have end-stage kidney disease
• The person needs a combined liver-kidney transplant but does not meet the required criteria

Kidney transplants are not recommended when the person has reversible kidney problems or health issues that would prevent success of transplant surgery. Some people may be temporarily unable to get a transplant until infections, heart or lung problems, or other serious conditions are treated. People with controlled HIV infection may be considered for transplant, as recent studies show high survival rates.

(Return to Description)

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Summary

This document outlines the medical necessity criteria for kidney transplantation, which involves surgically transferring a kidney from a deceased or living donor to a recipient with end-stage renal disease (ESRD). Kidney transplant is considered medically necessary for individuals with ESRD resulting from a wide range of congenital, hereditary, metabolic, vascular, toxic, obstructive, and inflammatory kidney conditions, as well as renal failure due to tumors, trauma, or unknown causes. Retransplantation is also considered medically necessary when a previous graft fails. Additionally, kidney transplantation may be performed as part of a simultaneous liver-kidney (SLK) transplant when specific criteria, such as prolonged dialysis, severely reduced kidney function, or biopsy-proven irreversible kidney damage, are met alongside eligibility for liver transplantation.

The document also specifies situations in which kidney transplantation is not considered medically necessary, primarily when ESRD is not present or SLK criteria are not met. Candidates must meet general selection criteria established by the American Society of Transplantation (AST), which exclude individuals with conditions such as metastatic cancer, severe untreated infections, serious cardiac insufficiency, untreatable comorbid conditions, or nonadherence to medical therapy. Certain individuals with controlled HIV may still qualify under defined clinical parameters.

Finally, the document reviews clinical guidelines and policy recommendations from Kidney Disease Improving Clinical Outcomes (KDIGO), Organ Procurement and Transplantation Network (OPTN)/United Network of Organ Sharing (UNOS), and transplant societies regarding appropriate evaluation and timing for transplantation, particularly in cases involving liver disease or reversible kidney failure. Data on national transplant trends and survival outcomes highlight the effectiveness of kidney transplantation, with reported 5-year survival rates above 86%. The text also discusses considerations surrounding hepatorenal syndrome, acute kidney injury, and chronic kidney disease, reaffirming transplantation as the preferred treatment in carefully selected patients.

Discussion

Approximately 35.5 million Americans are reported to have chronic kidney disease (CKD), with nearly 131,000 requiring initiation of treatment for kidney failure known as end stage renal disease (ESRD) each year (CDC, 2025). There was a steady rise in the rate of ESRD from 1980 to 2011; the incident rate of ESRD has started to decline. As of December 2025, the OPTN reported that there were 94,101 Americans on the wait list for kidney transplantation and, in 2025 through November, a total of 25,896 kidney transplants were performed (OPTN, 2025). According to data from the OPTN, for individuals receiving primary kidney transplants between 2008 and 2015, the 1-, 3- and 5-year survival rates were 97.1%, 93.0% and 86.6%, respectively.

A kidney transplant involves the surgical removal of a kidney from a deceased or living donor and implantation into a recipient. A donor left kidney is usually transplanted to the right iliac fossa with the renal artery anastomosed end-to-side to the external iliac artery and the renal vein anastomosed end-to-side to the external iliac vein. The ureter is implanted into the bladder and (under special conditions) a uretero-ureteral anastomosis or ureteropyelostomy may be performed.

Hepatorenal syndrome is a severe complication of liver cirrhosis or other severe liver disease. Features of hepatorenal syndrome are renal dysfunction caused by abnormalities in the arterial circulation and the vasoactive systems, resulting in renal vasoconstriction and renal insufficiency. There are two types of hepatorenal syndrome. Type I hepatorenal syndrome occurs when renal function is rapidly reduced and has an ominous prognosis which is usually reversed by liver transplantation. Type II hepatorenal syndrome occurs when renal failure does not progress rapidly. It can be quite difficult to distinguish these two conditions in individuals with severe liver disease. Liver transplantation is the recognized treatment for hepatorenal syndrome (Davis, 2005; Marik, 2006).

Concern has been raised since the introduction of the MELD (model for end-stage liver disease) prioritization for liver transplant that some recipients that undergo combined liver and kidney transplantation may have reversible renal failure. To address this issue, the American Society of Transplantation and American Society of Transplant Surgeons met in March 2006 to review post-MELD data on the impact of renal function on liver waitlist and transplant outcomes and the result of simultaneous liver kidney transplantation. This committee issued a consensus statement with regard to simultaneous liver-kidney (SLK) transplantation summarized below (Davis, 2007):

• In the setting of chronic kidney disease, a measured creatinine clearance of less than or equal to 30cc/min was considered the appropriate threshold for SLK transplantation.
• In the setting of acute renal failure secondary to hepatorenal syndrome or acute kidney injury, renal dysfunction requiring dialysis reflects a decreased capacity for renal recovery and SLK transplantation is considered appropriate. The committee through consensus established a six (6) weeks dialysis duration threshold prior to SLK transplantation.
• In individuals with prolonged acute kidney failure or kidney failure of unknown cause and a renal biopsy showing fixed renal damage (e.g. greater than 30-50% glomerulosclerosis, arteriolar hyalinosis, tubular atrophy, interstitial fibrosis) SLK may be medically necessary.
• In the setting of acute renal failure including hepatorenal syndrome not requiring dialysis, SLK transplantation was not felt to be medically necessary or appropriate. In reaching this consensus, the committee determined that liver transplant recipients with a glomerular filtration rate (GFR) of less than 30cc/min had a 1-year post-transplant survival of 81.5% and only 25/1648 (1.5%) of these recipients were listed for kidney transplant within a year of liver transplantation.

The 2020 KDIGO clinical practice guideline on evaluation and management of candidates for kidney transplantation, developed by an international group of experts, recommended that individuals with chronic kidney disease who are expected to reach end-stage kidney disease be considered for kidney transplantation, except for individuals with the following conditions:

• Multiple myeloma, light chain deposition disease or heavy chain deposition disease unless they have successfully received a curative treatment;
• AL amyloidosis with significant extrarenal involvement;
• Decompensated cirrhosis (these individuals can be considered for SLK);
• Severe irreversible obstructive or restrictive lung disease; and
• Severe uncorrectable symptomatic cardiac disease determined by a cardiologist to preclude transplantation.

In addition, the KDIGO guideline recommends that kidney transplant evaluation be delayed for individuals with the following conditions until they have been satisfactorily managed:

• Unstable psychiatric disorder or current substance abuse disorder that affects decision-making and puts the individual at an unacceptable level of post-transplant risk;
• Ongoing health-compromising behavior;
• Active infection that is not properly treated (excluding hepatitis C);
• Active malignancy other than indolent and low-grade cancers;
• Active symptomatic cardiac disease that has not been evaluated by a cardiologist;
• Active symptomatic peripheral arterial disease;
• Recent stroke or transient ischemic attack;
• Active peptic ulcer disease, diverticulitis, acute pancreatitis, gallstone or gallbladder disease or inflammatory bowel disease;
• Acute hepatitis; or
• Severe hyperparathyroidism.

In 2017, UNOS implemented policy changes for SLK transplantation based on changes the UNOS/OPTN board recommended. The decision was made based on subjective criteria to implement the new SLK allocation policy to standardize utilization for SLK. Individuals meeting the SLK allocation policy are defined based on the following criteria: sustained kidney injury with estimated glomerular filtration rate (eGFR) < 60 mL/min for 90 days or more with a final eGFR <30 mL/min (UNOS, 2022).

Controlled HIV infection is not considered a contraindication to kidney transplant (Chadban, 2020). In 2019, Zheng and colleagues published a meta-analysis of studies on outcomes after kidney transplantation in HIV-positive individuals. The meta-analysis included 27 cohort studies and 1670 case series published between July 2003 and May 2018. The authors found a pooled 1-year survival rate of 97% and a 5-year survival rate of 94%.

Allotransplantation: The transfer of cells, tissues, or whole organs from one individual to another within the same species.

Chronic renal disease: The permanent loss of kidney function.

End stage renal disease: Persistent decline in renal function as documented by falling creatinine clearance/glomerular filtration rate in an individual diagnosed with a renal disease whose natural history is progression to renal impairment requiring current or impending renal replacement (dialysis or transplant).

Nephropathy: Refers to damage or disease of the kidney.

Peer Reviewed Publications:

1. Bleyer AJ, Donaldson LA, McIntosh M, et al. Relationship between underlying renal disease and renal transplantation outcome. Am J Kidney Dis. 2001; 37(6):1152-1161.
2. Cecka JM. The UNOS scientific renal transplant registry - 2000. Clin Transpl. 2000:1-18.
3. Davis C, Feng S, Sung R, et al. Simultaneous liver-kidney transplantation: evaluation to decision making. Am J Transplant. 2007; 7(7):1702-1709.
4. Davis CL. Impact of pretransplant renal failure: when is listing for kidney-liver indicated? Liver Transpl. 2005; 11(11 Suppl 2):S35-S44.
5. Gjertson DW, Cecka JM. Determinants of long-term survival of pediatric kidney grafts reported to the United Network for Organ Sharing kidney transplant registry. Pedatr Transplant. 2001; 5(1):5-15.
6. Gjertson DW, Cecka JM. Living unrelated donor kidney transplantation. Kidney Int. 2000; 58(2):491-498.
7. Ishitani M, Isaacs R, Norwood V, et al. Predictors of graft survival in pediatric living-related kidney transplant recipients. Transplantation. 2000; 70(2):288-292.
8. Krishnan N, Higgins R, Short A, et al. Kidney transplantation significantly improves patient and graft survival irrespective of BMI: a cohort study. Am J Transplant. 2015; 15(9):2378-2386.
9. Marik PE, Wood K, Starzl TE. The course of type 1 hepato-renal syndrome post liver transplantation. Nephrol Dial Transplant. 2006; 21(2):478-482.
10. Martínez-Vaquera S, Navarro Cabello MD, López-Andreu M, et al. Outcomes in renal transplantation with expanded-criteria donors. Transplant Proc. 2013; 45(10):3595-3598.
11. Pieloch D, Dombrovskiy V, Osband AJ, et al. Morbid obesity is not an independent predictor of graft failure or patient mortality after kidney transplantation. J Ren Nutr. 2014; 24(1):50-57.
12. Steinman T, Becker BN, Frost AE, et al. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation. 2001; 71(9):1189-1204.
13. Tejani A, Sullivan EK. Do six-antigen-matched cadaver donor kidneys provide better graft survival to children compared with one-haploidentical living-related donor transplants? Pediatr Transplant. 2000; 4(2):140-145.
14. Zheng X, Gong L, Xue W, et al. Kidney transplant outcomes in HIV-positive patients: a systematic review and meta-analysis. AIDS Res Ther. 2019;16(1):37.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Nephrology. Available at: https://www.asn-online.org/. Accessed on February 13, 2026.
2. Centers for Disease Control and Prevention. Chronic kidney disease. Last reviewed June 3, 2024. Available at: https://www.cdc.gov/cdi/indicator-definitions/chronic-kidney-disease.html. Accessed on February 13, 2026.
3. 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.
4. Organ Procurement and Transplantation Network.
   • National Data. Available at: https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/. Accessed on February 13, 2026.
   • Policy 8 Allocation of Kidneys; Policy 9.9 Liver-Kidney Allocation. Last updated December 4, 2025. Available at: https://optn.transplant.hrsa.gov/media/r0idd5a2/optn_policies.pdf. Accessed on February 13, 20265.
5. United Network for Organ Sharing. Available at: http://www.unos.org/. Accessed on February 13, 2026.

Hepatorenal Syndrome
Kidney Transplantation
Renal Allotransplantation
Renal Transplantation
Transplantation, Kidney