Life After Kidney Transplant: Rejection, Drugs and Survival

Life after a kidney transplant depends on three things: taking immunosuppressive medicines for life, exactly on time; regular blood and urine tests to catch rejection early; and strict food hygiene. With that discipline, about 97% of transplanted kidneys are working at one year and around 60% of grafts and patients survive at 15 years, by the figures of Dr. Y P S Rana of BLK-Max Super Speciality Hospital, New Delhi.

Dr. Yajvender Pratap Singh Rana, Senior Director - Urology, Uro-Oncology, Andrology and Kidney Transplant, BLK-Max Super Speciality Hospital, New Delhi, India, spent much of his November 2025 masterclass answering what happens after the operation: how long the danger period lasts, how rejection is recognised and reversed, what the medicines cost and how a patient living thousands of kilometres from the transplant centre stays safe. This article covers that ground. The steps before surgery, from donor rules to cost, are in kidney transplant for international patients, and the wider series begins with advances in urology, uro-oncology and kidney transplant.

Kidney transplant success rates

Dr. Rana's first point on outcomes was comparative: a kidney transplant is always better than staying on dialysis. His survival figures for transplanted kidneys:

Kidney function at discharge is typically a serum creatinine of around 0.9 to 1.2 mg/dL. As immunosuppression is titrated over the following weeks, creatinine usually settles at around 0.9 to 1.

The long tail of the curve is illustrated by one of his patients, a man now in his forties who received his mother's kidney about 15 to 16 years before the masterclass. He works as a manager, his creatinine is 0.9, and his mother, the donor, is also alive and well.

Why grafts fail later on

If the one-year survival is 97%, why does it fall over time? Rejection is part of the answer. It can happen at any time, including late, although the rate falls steadily the further a patient is from surgery.

Dr. Rana pointed to behaviour as the other part. Patients often become casual five or eight years after the transplant and start taking things for granted. Missed medicines lead to rejection or infection, the kidney fails, and the patient lands back on dialysis needing a second transplant. If a graft does fail, it usually happens 10 to 15 years after the transplant. That is why his counselling from the first consultation is blunt: this is your next life, and every precaution exists to prolong the graft.

Life after kidney transplant: the critical first three months

The first two to three months are the most critical period. International patients usually stay in India for two to three months after the operation for exactly this reason. If everything goes smoothly in that window, the chance of severe rejection later is very low. Serious rejection that develops overnight is an early phenomenon.

Recognising rejection

Early, acute and chronic

Dr. Rana described the categories in turn.

• Hyperacute rejection, which destroys the kidney within minutes to hours, has effectively disappeared from his practice. With modern immunosuppression he has not seen a case in ABO-compatible transplant in the last 10 to 12 years. It can still occur in ABO-incompatible transplant.
• Early rejection can appear as soon as one to two weeks after transplant.
• Acute rejection at any stage is either cellular (T-cell-mediated, often called ACR) or antibody-mediated (AMR).
• Chronic rejection develops over a longer period.

Warning signs of kidney transplant rejection

The clues are simple and can be tracked anywhere: a creatinine that was very low and starts creeping up, and protein appearing in the urine. Protein in the urine is the first marker that the kidney is in trouble. When these signs appear, a kidney biopsy confirms whether rejection is present and which type it is.

How kidney transplant rejection is treated

Treatment depends on the type. For cellular rejection, Dr. Rana's sequence is a pulse of methylprednisolone (a high-dose intravenous steroid) first and, if that does not work, ATG (anti-thymocyte globulin). For antibody-mediated rejection his sequence escalates further to plasmapheresis to remove antibodies; guidelines treat antibody-mediated rejection from the outset with plasmapheresis, usually combined with intravenous immunoglobulin.

Most rejections today are reversible, and once rejection is reversed the kidney adapts and recovers its function. The danger lies in delay. Problems arise when rejection is treated late rather than promptly; otherwise, in his words, "rejections are easy to manage".

Lifelong immunosuppression after kidney transplant

No days off

Do transplant patients need immunosuppression for life? "100%," Dr. Rana answered. The medicines are taken morning and evening, at the same time by the clock, at exactly the dose prescribed. They keep the immune system "in the silent mode". Stop them, and the immune system reactivates and destroys the kidney.

He told the story of a young man transplanted in his early twenties who was doing perfectly several years later, until he forgot to take his immunosuppression during three days of his own wedding celebrations. Dr. Rana did not need to spell out the consequence.

The standard regimen

Most recipients receive a three-drug maintenance regimen built from a steroid, a calcineurin inhibitor (tacrolimus or cyclosporine) and mycophenolate.

The art of balancing

Lower immunity raises the risk of other infections. Dr. Rana calls managing this "the art of balancing": immunity must be kept as low as the kidney needs, but not so low that the patient is exposed to opportunistic infections. Nowadays that balance is closely monitored.

Cost of anti-rejection medicines

After the first three months, Dr. Rana put the cost of anti-rejection medicines at around USD 100 a month, about 8,000 rupees. Doses are higher for the first two to three months, and these drugs are not priced like cancer drugs. Many of his international patients return every year for a full check-up and take a year's supply of medicines home, saving money in the process.

Kidney transplant follow-up from another country

The routine

Follow-up is every three months as a routine, with:

• serum creatinine;
• a urine routine examination, including protein;
• strict adherence to the immunosuppressive regimen.

Dr. Rana gives his international patients his personal number, his secretary's number and the transplant coordinators' contacts, because they need to stay in touch.

When rejection is suspected years later

The scenario that worries referring doctors is a patient back home, five years after transplant, whose creatinine starts to rise. How much time is there to act?

Enough, in Dr. Rana's view, because rejection that starts late is "not the overnight emergency". Most of his transplant patients are followed by a nephrologist in their own country, and he cited nephrologists in Ethiopia who discuss such patients with his team. The pathway he described:

1. The local nephrologist notes rising creatinine and urinary protein and suspects rejection.
2. A transplant biopsy is performed locally, with the specimen read locally or sent to India.
3. If rejection is confirmed, treatment is guided by telephone. Drugs such as ATG are now available in countries such as Tanzania, so patients can often be treated at home.
4. If local treatment is not possible, the team advises adjusting the immunosuppression dose to the right level for the time being, and the patient then plans travel back to India.

Delayed graft function

Delayed graft function means the transplanted kidney does not work properly immediately after surgery and the patient may need dialysis until it recovers. In a living related transplant, Dr. Rana said, it should not happen; if it does, it points to a problem during organ retrieval, which is why choosing a good centre and surgeon matters so much.

In deceased-donor transplant it is a known risk, linked to cold ischaemia time, the hours a kidney spends chilled outside the body. His team aims to implant the kidney within 12 hours, and within six hours if possible, organising everything in parallel. When delayed function does occur, it is usually acute tubular necrosis (ATN), a temporary injury to the kidney's tubules that generally recovers. Immunosuppression is modified meanwhile: tacrolimus is withheld, and more steroid and ATG are given.

Second and third transplants

A second transplant carries slightly higher risk than the first, because the body is already sensitised to foreign tissue antigens, but it still gives a better outcome than dialysis. Dr. Rana has also performed a third transplant, for a boy who had already received two.

When a graft fails very early, surgery can be part of the cause. Any trauma to the kidney or its vessels during the operation can cause thrombosis, and that thrombosis creates problems in the early phase. Delicate handling of the artery and vein is paramount, and good surgery is the main defence against early surgical complications.

Two other questions recur. A failed transplanted kidney can never be removed and given to another patient: if it has failed, it is damaged beyond recovery. And a recipient never needs two kidneys: a single transplanted kidney is enough, and the patient's own kidneys usually stay in place.

Diet after kidney transplant

Dr. Rana's dietary rule is about hygiene rather than restriction. Food must be properly cooked and hygienically prepared, and street food is out. Otherwise patients can eat normally, including chicken and the local foods available in their own country.

A partnership between two doctors

A transplant is not a one-time operation but a long follow-up, and Dr. Rana closed by inviting referring doctors to stay in touch and discuss cases with him directly. Outcomes are better when the local doctor and the transplant team stay connected, sharing results and decisions across the distance. Doctors' questions on rejection, survival and diet from the session are recorded on the Live Discussion page, and more on kidney care is on the nephrology hub.