Kidney transplant & dialysis for PKD

PKD, nephrectomy and kidney transplant: frequently asked questions

Most people with PKD do not automatically have their own kidneys removed when they receive a transplant. A nephrectomy may be recommended if an enlarged kidney leaves too little room for the transplant or causes serious pain, infections, bleeding, stones, pressure symptoms or concern about cancer.

The timing depends on the reason for removal, remaining kidney function, donor type and surgical risk. Whenever possible, current guidance favours removing only one kidney and doing it at the time of transplant or afterward rather than before.

Learn why PKD kidneys may be removed before, during or after a kidney transplant, when nephrectomy is needed, and what to ask your transplant team.

Do my polycystic kidneys have to be removed before a kidney transplant?

Usually, no. Most people with polycystic kidney disease (PKD) keep their own kidneys when they receive a kidney transplant.

The transplanted kidney is normally placed in the lower abdomen rather than where the person’s original kidneys are located. The native PKD kidneys may be left in place unless they are causing serious symptoms, complications or problems with the transplant surgery.

Current KDIGO guidance recommends removing a native PKD kidney only when there is a specific medical reason and the likely benefit outweighs the risks of surgery.

What is a nephrectomy?

A nephrectomy is surgery to remove a kidney.

For people with autosomal dominant polycystic kidney disease (ADPKD), a surgeon may remove:

  • one native kidney, called a unilateral nephrectomy
  • both native kidneys, called a bilateral nephrectomy

When possible, current guidance favours removing only one kidney rather than both. This may make the surgery less extensive and allow the remaining kidney to continue producing urine or providing a small amount of kidney function.

Why might a PKD kidney need to be removed?

A nephrologist or transplant surgeon may recommend removing a native PKD kidney if it is causing a serious problem.

Possible reasons include:

  • there is not enough room in the abdomen for the transplanted kidney
  • repeated or severe kidney or cyst infections
  • repeated or severe bleeding from kidney cysts
  • ongoing blood in the urine caused by cyst bleeding
  • severe kidney pain that has not improved with other treatments
  • kidney stones that continue to cause significant symptoms
  • pressure or discomfort caused by massively enlarged kidneys
  • difficulty eating or feeling full very quickly because of enlarged kidneys
  • an abdominal-wall hernia complicated by very large kidneys
  • concern that a kidney mass could be cancer

Having large kidneys does not automatically mean they must be removed. The transplant team will consider the kidney’s size, position, symptoms and effect on the planned transplant.

Can enlarged PKD kidneys leave too little room for a transplant?

Yes. PKD kidneys can become very large and take up considerable space in the abdomen.

Although a transplanted kidney is usually placed in the lower abdomen, the surgeon still needs enough space to safely position it and connect it to nearby blood vessels and the bladder. If one native kidney is blocking the safest location for the transplant, the surgeon may recommend removing that kidney.

Imaging, such as a CT scan or MRI, helps the transplant team evaluate kidney size and plan the surgery.

Why would a PKD kidney be removed before transplant?

A nephrectomy may be performed before transplant when a native kidney is causing a serious problem that should not wait.

Examples may include:

  • a severe or recurring infection
  • significant bleeding
  • disabling pain or pressure
  • suspected kidney cancer
  • too little space to safely perform the transplant

Removing a kidney before transplant may also be easier to plan when a person has a scheduled living-donor transplant.

However, removing a kidney before transplant has disadvantages. Even a kidney that is functioning poorly may still produce urine or provide some remaining kidney function. Removing it could make dialysis necessary sooner or make fluid management more difficult.

Surgery can also lead to blood loss and the need for a transfusion. Blood transfusions can sometimes cause the immune system to develop antibodies, known as sensitization, which may make it harder to find a compatible donor kidney.

For these reasons, KDIGO recommends doing the nephrectomy at the time of transplant or afterward, rather than before transplant, whenever possible.

Why would a nephrectomy be done at the same time as a kidney transplant?

A surgeon may remove a native PKD kidney during the same operation as the transplant.

This may be considered when:

  • the kidney must be removed to make room for the transplant
  • the native kidney is causing serious pain, bleeding or infections
  • the person is healthy enough for a longer and more complex operation
  • the transplant involves a living donor and can be planned in advance
  • the transplant centre has experience performing both procedures together

A simultaneous nephrectomy and kidney transplant may mean one anaesthetic, one hospital stay and one main recovery period. The new kidney can also begin working as the native kidney is removed.

However, the combined surgery may take longer and involve more blood loss, a greater chance of transfusion and a more difficult recovery. The risks and benefits depend on the person’s health and the transplant centre’s surgical experience.

Why might the transplant team wait until after the transplant?

When it is safe to do so, the team may perform the transplant first and leave the native kidneys in place.

Waiting may allow the person to:

  • keep any remaining kidney function before transplant
  • continue producing urine
  • avoid delaying the transplant
  • avoid an additional operation unless it becomes necessary
  • recover from the transplant before facing another major surgery

Some enlarged PKD kidneys may also shrink after a successful transplant. Symptoms may improve enough that nephrectomy is never needed.

A kidney can still be removed later if it continues to cause serious pain, infection, bleeding, stones or pressure symptoms. Surgery after transplant must be planned carefully because anti-rejection medications can affect infection risk and healing.

Is it better to remove a PKD kidney before or after transplant?

There is no single answer that is right for everyone.

When a nephrectomy is required, current KDIGO guidance generally favours performing it at the time of transplant or afterward, instead of before transplant, whenever possible.

The best timing may depend on:

  • why the kidney needs to be removed
  • whether there is enough room for the transplanted kidney
  • how much kidney function remains
  • how much urine the native kidneys still produce
  • whether the person is already receiving dialysis
  • the severity of pain, infections or bleeding
  • whether the donor is living or deceased
  • the person’s general health and surgical risk
  • whether one or both kidneys may need to be removed
  • the experience of the transplant centre
  • the patient’s preferences

The nephrologist, transplant surgeon and patient should make the decision together.

Will both of my PKD kidneys be removed?

Not necessarily. In many cases, neither kidney is removed.

When nephrectomy is needed, the surgeon may remove only the kidney causing the greatest problem or the kidney occupying the space needed for the transplant.

Removing both kidneys is a larger operation. It also eliminates any remaining kidney function and urine production from the native kidneys. Current KDIGO guidance therefore favours removing one kidney rather than both when one nephrectomy will adequately address the problem.

Both kidneys may need to be removed in some circumstances, such as when both are causing severe infections, bleeding, pain or pressure symptoms.

Where is the transplanted kidney placed if my PKD kidneys remain?

A transplanted kidney is usually placed in the lower abdomen or pelvis, often on the right or left side.

The surgeon connects the donor kidney to blood vessels in that area and connects its ureter, the tube that carries urine, to the bladder.

The transplanted kidney does not normally replace one of the native kidneys in its original position. This is why many people can keep both of their PKD kidneys after transplant.

Can my PKD kidneys still cause problems after a transplant?

Yes, although many people do not need further surgery.

A native PKD kidney may continue to cause:

  • pain
  • cyst infections
  • cyst bleeding
  • blood in the urine
  • kidney stones
  • pressure or fullness in the abdomen
  • problems related to its size

If symptoms become serious after transplant, the transplant team may discuss removing one or both native kidneys.

Do PKD kidneys shrink after a kidney transplant?

They may. Native PKD kidneys often decrease in size after a successful transplant, although the amount and timing vary from person to person.

This is one reason a transplant team may choose to wait before recommending nephrectomy. If the kidneys shrink and symptoms improve, surgery may not be necessary.

What are the risks of nephrectomy for someone with PKD?

As with any major operation, nephrectomy can involve risks such as:

  • bleeding
  • blood transfusion
  • infection
  • blood clots
  • injury to nearby organs or blood vessels
  • pain and a longer recovery
  • complications related to anaesthesia
  • loss of remaining kidney function
  • reduced or absent urine production if both kidneys are removed

PKD kidneys can be unusually large and have a complex blood supply, which may make surgery more challenging. The surgical team will assess whether the likely benefits outweigh these risks.

What questions should I ask my nephrologist or transplant surgeon?

You may want to ask:

  • Do you expect that one of my native kidneys will need to be removed?
  • What specific problem would the nephrectomy address?
  • Is there enough room for the transplanted kidney?
  • Would you recommend removing one kidney or both?
  • Could the surgery wait until after my transplant?
  • What are the benefits and risks of doing both procedures at the same time?
  • Would removing a kidney make me need dialysis sooner?
  • How much urine and kidney function do my native kidneys still provide?
  • How likely am I to need a blood transfusion?
  • Could a transfusion affect my transplant compatibility?
  • Would the operation be open, laparoscopic or hand-assisted laparoscopic surgery?
  • How often does this transplant centre perform nephrectomies for people with PKD?
  • How might each option affect my hospital stay and recovery?
  • What could happen if we leave my native kidneys in place?

What should I tell my healthcare team about my symptoms?

Tell your nephrologist or transplant team if you experience:

  • repeated fevers or suspected kidney infections
  • severe or increasing kidney or abdominal pain
  • repeated blood in your urine
  • difficulty eating or feeling full after small amounts of food
  • increasing abdominal pressure or swelling
  • recurring kidney stones
  • a new lump or unusual change in your abdomen
  • symptoms that are affecting sleep, movement or quality of life

Describing how often symptoms happen and how they affect daily life can help the team decide whether nephrectomy should be considered.

What is the main thing to remember about nephrectomy and PKD transplant?

Most people with PKD do not automatically need their native kidneys removed when they receive a transplant.

A nephrectomy may be recommended when a kidney is causing serious pain, infections, bleeding, stones or pressure symptoms, when there is concern about cancer, or when there is not enough room for the transplanted kidney.

The decision about whether and when to remove a kidney should be individualized and made jointly by the patient, nephrologist and transplant surgeon.

Note: This summary was created with help from artificial intelligence (AI). We’ve done our best to make sure it’s clear and accurate, but it may still contain some errors. Always check with your healthcare provider or the original research (link above) if you have questions about this topic.

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