EAU 2025 Guidelines: Renal Transplantation

What This Guideline Covers

The EAU 2025 Renal Transplantation guideline provides evidence-based recommendations across 25 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

• Offer pure or hand-assisted laparoscopic/ retroperitoneoscopic surgery as the preferential technique for living-donor nephrectomy.
• Perform open living-donor nephrectomy in centres where endoscopic techniques are not implemented.
• Perform laparo-endoscopic single site surgery, robotic and natural orifice transluminal endoscopic surgery-assisted living-donor nephrectomy in highly- specialised centres only.

Kidney storage solutions

• Use either University of Wisconsin or histidine tryptophane ketoglutarate preservation solutions for cold storage.
• Use Celsior or Marshall’s solution for cold storage if University of Wisconsin or histidine tryptophane ketoglutarate solutions are not available.

Kidney preservation: static and dynamic preservation

• Minimise ischaemia times.

• Use hypothermic machine-perfusion (where available) in deceased donor kidneys to reduce delayed graft function.

• Hypothermic machine-perfusion may be used in standard criteria deceased donor kidneys.

• Use low pressure values in hypothermic machine perfusion preservation.

• Hypothermic machine-perfusion must be continuous and controlled by pressure and not flow.

• Do not base decisions on the acceptance of a donor organ on histological findings alone, since this might lead to an unnecessary high rate of discarded grafts. Interpret histology in context with clinical parameters of donor and recipient, including perfusion parameters where available.

• Use paraffin histology for histomorphology as it is superior to frozen sections; however, its diagnostic value has to be balanced against a potential delay of transplantation.

• Procurement biopsies should be read by a renal pathologist or a general pathologist with specific training in kidney pathology.

• Use single-dose, rather than multi-dose, peri-operative prophylactic antibiotics in routine renal transplant recipients.

• Optimise pre-, peri- and post-operative hydration to improve renal graft function.

• Use target directed intra-operative hydration to decrease delayed graft function rates and optimise early graft function.

• Assess the utility (including inspection) of the kidney for transplantation before commencement of immunosuppression and induction of anaesthesia for deceased donor kidney transplantation.

• Check the intima of the donor and recipient arteries prior to commencing the arterial anastomosis to ensure that there is no intimal rupture/flap. If this is found it must be repaired prior to/as part of the arterial anastomosis.

• Pre-operatively plan the surgical approach in third or further transplants, to ensure that appropriate arterial inflow and venous outflow exists with adequate space to implant the new kidney.

• Perform Lich-Gregoir-like extra-vesical ureteric anastomosis technique to minimise urinary tract complications in renal transplant recipients with normal urological anatomy.

• Pyelo/uretero-ureteral anastomosis is an alternative especially for a very short or poorly vascularised transplant ureter.

• Use transplant ureteric stents prophylactically to prevent major urinary complications.

• Use the same surgical principals for single ureters to manage duplex ureters and anastomose them either separately or combined.

• Restrict living donor nephrectomy to specialised centres.

• Offer long-term follow-up to all living kidney donors.

• Perform ultrasound-colour-doppler in case of suspected graft thrombosis.

• Perform surgical exploration in case of ultrasound finding of poor graft perfusion.

• Perform an allograft nephrectomy in case of a non-viable graft.

• Perform ultrasound-colour-doppler in case of suspected graft thrombosis.

• Do not routinely use pharmacologic prophylaxis to prevent transplant renal vein thrombosis.

• Perform ultrasound-colour-doppler to diagnose an arterial stenosis, in case of undetermined results on ultrasound consider a magnetic resonance or computed tomography angiogram.

• Perform percutaneous transluminal angioplasty/stent, if feasible, as first-line treatment for an arterial stenosis.

• Offer surgical treatment in case of recent transplant, multiple, long and narrow stenosis, or after failure of angioplasty.

• Perform a ultrasound-colour-doppler if a arteriovenous fistulae or pseudo-aneurysm is suspected.

• Perform angiographic embolisation as first- line treatment in symptomatic cases of arteriovenous fistulae or pseudo-aneurysm.

• Perform percutaneous drainage placement as the first treatment for large and symptomatic lymphocele.

• Perform fenestration when percutaneous treatments fail.

• Manage urine leak by JJ-stent and bladder catheter and/or percutaneous nephrostomy tube.

• Perform surgical repair in cases of failure of conservative management.

• In case of ureteral stricture, place a nephrostomy tube for both kidney decompression and stricture diagnosis via an antegrade pyelogram.

• Manage strictures < 3 cm in length either with surgical reconstruction or endoscopically (percutaneous balloon dilation or antegrade flexible ureteroscopy and holmium laser incision).

• Treat late stricture recurrence and/or stricture > 3 cm in length with surgical reconstruction in appropriate recipients.

• Evaluate the causes of urolithiasis in the recipient.

• Treat ureteral obstruction due to a stone with a percutaneous nephrostomy tube or JJ-stent placement.

• Perform shockwave lithotripsy or antegrade/retrograde ureteroscopy for stones < 15 mm.

• Be aware of the presence of a kidney transplant in the pelvis and the possibility of subsequent transplants when planning treatment for prostate cancer.

• Refer kidney transplant patients with prostate cancer to an integrated transplant urology centre.

• Determine the ABO blood group and the human leukocyte antigen A, B, C and DR phenotypes for all candidates awaiting kidney transplantation.

• Test both the donor and recipient for human leukocyte antigen DQ. Human leukocyte antigen DP testing may be performed for sensitised patients.

• Perform thorough testing for HLA antibodies before transplantation.

• Perform adequate cross-match tests to avoid hyper-acute rejection, before each kidney and combined kidney/pancreas transplantation.

• Perform initial rejection prophylaxis with a combination therapy of a calcineurin inhibitor (preferably tacrolimus), mycophenolate, steroids and an induction agent (either basiliximab or anti-thymocyte globulin).

• Use calcineurin inhibitors for rejection prophylaxis as they represent current best practice pending publication of long-term results using newer agents.

• Use tacrolimus as first-line calcineurin inhibitor due to its higher efficacy.

• Monitor blood-levels of both cyclosporine and tacrolimus to allow appropriate dose adjustment of calcineurin inhibitors.

• Administer mycophenolate as part of the initial immunosuppressive regimen.

• Initial steroid therapy should be part of immunosuppression in the peri-operative and early post-transplant period.

• Significantly reduce calcineurin inhibitor dosage in a combination regimen with m-TOR inhibitors to prevent aggravated nephrotoxicity.

• Do not convert patients with proteinuria and poor renal function to m-TOR inhibitors.

• Monitor blood-levels of both sirolimus and everolimus to allow for appropriate dose adjustment.

• Monitor transplant recipients for signs of acute rejection, particularly during the first six months post-transplant.

• Take regular blood samples in addition to regular monitoring of urine output and ultrasound examinations in order to detect graft dysfunction during hospitalisation.

• Immediately rule out other potential causes of graft dysfunction in cases of suspected acute rejection. An ultrasound of the kidney transplant should be performed.

• Perform a renal biopsy, graded according to the most recent Banff criteria, in patients with suspected acute rejection episodes.

• Only if contraindications to renal biopsy are present, can ‘blind’ steroid bolus therapy be given.

• Test patients who suffer acute rejection as soon as possible for anti-HLA antibodies against the graft.

• Reassess the immunosuppressive therapy of all patients with rejection, including patient adherence to the medication, which is of particular importance in late rejections.

• Prevent hyper-acute rejection by adequate ABO blood group and HLA matching of donor and recipients.

• Use steroid bolus therapy as first-line treatment for T-cell mediated rejection in addition to ensuring adequate baseline immunosuppression.

• In severe or steroid-resistant rejection, use intensified immunosuppression, high-dose steroid treatment, and eventually T-cell depleting agents.

• Treatment of antibody mediated rejection should include antibody elimination.

• Provide lifelong regular post-transplant follow-up by an experienced and trained transplant specialist at least every six to twelve months.

• Advise patients on appropriate lifestyle changes, potential complications, and the importance of adherence to their immunosuppressive regimen.

• Regularly monitor (approximately every four to eight weeks) serum creatinine, estimated glomerular filtration rate, blood pressure, urinary protein excretion, immunosuppression and complications after renal transplantation. Changes in these parameters over time should trigger further diagnostic work-up including renal biopsy, a search for infectious causes and anti-HLA antibodies.

• Perform an ultrasound of the graft, in case of graft dysfunction, to rule out obstruction and renal artery stenosis.

• In patients with interstitial fibrosis and tubular atrophy undergoing calcineurin inhibitor therapy and/or with histological signs suggestive for calcineurin inhibitor toxicity (e.g., arteriolar hyalinosis, striped fibrosis) consider calcineurin inhibitor reduction or withdrawal.

• Initiate appropriate medical treatment, e.g., tight control of hypertension, diabetes, proteinuria, cardiac risk factors, infections, and other complications according to current guidelines.