Living with one kidney after nephrectomy: function, check-ups and daily life

Can you live a normal life with one kidney?

Yes. Most people with one healthy kidney live a normal life, without dialysis, a special diet or limits at work. What changes is that the remaining kidney has no partner in reserve, so it needs regular checks and some care for the rest of your life.

This article is for people who have had, or are about to have, a whole kidney removed for a tumour (radical nephrectomy). Whether the kidney can be kept instead is a separate question, explained in partial or radical nephrectomy. Treatment by size and stage is on the kidney tumours page.

The remaining kidney adapts in two ways. Each of its tiny filters receives more blood and filters more than before (doctors call this hyperfiltration), and over the following months the kidney grows somewhat larger. Together these changes win back part of the lost function, though not all of it. That is why a blood test after surgery does not show half of what you had before. The adaptation tends to be weaker in older people and in those with other illnesses.

How much kidney function will you have after kidney removal?

Less than before, but usually enough: in the randomised trial, a moderately reduced filtration rate was common after radical nephrectomy and kidney failure was rare.

Kidney function is reported as eGFR (estimated glomerular filtration rate), a figure calculated from the creatinine level in a blood sample. The lower the number, the less the kidneys filter. In the trial below, an eGFR under 60 was classed as at least moderate dysfunction, under 30 as advanced kidney disease and under 15 as kidney failure.

The EORTC 30904 trial enrolled patients with a small tumour (5 cm or less) and a normal second kidney, and assigned them by chance to radical or partial nephrectomy. Follow-up eGFR was recorded for 259 patients after radical and 255 after partial nephrectomy, over a median of 6.7 years.

Limits: the trial percentages use the lowest eGFR recorded during follow-up, so they include anyone who dipped below a threshold once. Patients were enrolled from 1992 to 2003, all had a small tumour and a normal second kidney, and the authors state that longer follow-up of kidney function is missing. The studies by Huang and Lane are retrospective and come from single centres, and the Lane figures cover partial and radical operations together.

Two messages follow. Removing a whole kidney makes a moderately reduced eGFR very common: 85.7% after radical against 64.7% after partial nephrectomy. Yet kidney failure was rare and no more frequent after radical surgery in this trial: 1.5% against 1.6%.

What do living kidney donors teach us, and why are tumour patients different?

Donors show that a healthy person can live for decades with one kidney at a small added risk of kidney failure. Tumour patients start from a less favourable position.

• Ibrahim 2009 (3,698 donors, 1963 to 2007). Survival was similar to that of matched controls. In 255 donors examined a mean of 12.2 years after donation, 85.5% had a GFR of 60 or higher, 32.1% had high blood pressure and 12.7% had albumin in the urine.
• Muzaale 2014 (96,217 US donors). The estimated risk of kidney failure 15 years after donation was 30.8 per 10,000 donors, against 3.9 per 10,000 matched healthy non-donors. The lifetime estimate was 90 per 10,000 donors and 326 per 10,000 in the unscreened general population.
• Mjøen 2014 (1,901 Norwegian donors, median follow-up 15.1 years). Compared with people who would have been eligible to donate, the hazard ratio was 1.30 for death from any cause and 11.38 for kidney failure.
• O'Keeffe 2018 (meta-analysis, 52 studies, 118,426 donors). No evidence of higher mortality, cardiovascular disease, high blood pressure or type 2 diabetes. The relative risk of kidney failure was 8.83, while the absolute rate stayed low at 0.5 events per 1,000 person-years.

All of these are observational studies, and their results depend on which comparison group is chosen. More importantly, donors are selected because they are healthy. People with a kidney tumour are not screened in that way: they are often older, more of them have diabetes or high blood pressure, and many already have reduced function. In the Huang study, 26% of patients with a small tumour and a normal creatinine had chronic kidney disease by eGFR before surgery; in the Lane registry, 28% had an eGFR below 60 before the operation. Donor figures are therefore the favourable end of the range, not a forecast for every patient.

Does living with one kidney shorten life expectancy?

No single figure exists for life expectancy with one kidney. The data suggest that losing a kidney to surgery has, on its own, little effect on survival, while kidney disease present before surgery, other illnesses and the tumour itself weigh more.

In EORTC 30904 (541 patients, median follow-up 9.3 years), 10-year overall survival was 81.1% after radical and 75.7% after partial nephrectomy. Keeping more kidney tissue did not lead to longer survival in this trial, and only 12 of 117 deaths were caused by kidney cancer. The result should be read with care: the trial closed early because recruitment was poor, and among patients with confirmed renal cell carcinoma the difference was no longer statistically significant. It does not show that removing the whole kidney is the better operation.

The Lane registry study (4,180 patients, median follow-up 6.6 years) separated two situations. Where kidney disease was present before surgery, the risk of death was 1.8, 3.5 and 4.4 times higher for stages 3, 4 and 5 than with normal function. In the 22% whose eGFR fell below 60 only after surgery, neither that fall nor the eGFR after surgery predicted survival. Function then declined by 0.7% a year, against 4.7% a year with pre-existing disease, and a loss of more than half of function occurred in 2.2% against 7.3%.

A likely explanation is that surgery removes tissue once and leaves a healthy kidney behind, whereas diabetes or high blood pressure keeps injuring the filters. The limits are real: this is a retrospective study from one institution with intermediate follow-up, and the Norwegian donor study found higher mortality after a median of 15.1 years. For younger patients, the very long term remains less certain.

Who is at higher risk of kidney failure after nephrectomy?

People whose remaining kidney is already under strain: older age, diabetes, high blood pressure, a reduced eGFR before surgery and protein in the urine.

• Diabetes, blood pressure, weight, age, smoking. In a retrospective series of 749 patients (Malcolm 2009, mean follow-up 6.4 years), the odds of developing an eGFR below 60 were higher with diabetes (odds ratio 8.96), high blood pressure (4.55), a body mass index of 30 or more (3.51), age 60 or over (2.91) and smoking (2.44).
• Function before surgery. In the Lane study, the eGFR before the operation was a strong predictor of survival.
• Protein in the urine. In 977 patients having kidney cancer surgery (Zhang 2016, retrospective, median follow-up 8.7 years), 33% had protein on a urine dipstick beforehand. Their 5-year overall survival was 65% against 77% without protein, and kidney function stayed stable in 72% against 86%.

The current European Association of Urology (EAU) guideline singles out patients with pre-existing or treatment-related kidney disease, for example a new baseline eGFR below 45, and advises referral to a kidney specialist (nephrologist) when function is at risk or deteriorating. Several of these factors can be influenced, which is the reason for the two sections that follow.

Which check-ups do you need, and how often?

Three simple checks, repeated for life: a blood test for creatinine and eGFR, a urine test for protein, and blood pressure. They run alongside the cancer follow-up. The EAU guideline states that surveillance should include kidney function and cardiovascular risk factors, and that this functional follow-up continues according to clinical need even after cancer imaging has ended. It gives no fixed interval for the kidney tests, so the intervals in the table reflect common practice.

Imaging follows the risk of recurrence. In the EAU schedule, low-risk patients have CT at 6, 18 and 30 months, and high-risk patients at 3, 6, 12, 18, 24 and 36 months, with longer intervals afterwards. Your own plan is set from the pathology report.

What should you do in daily life to protect the kidney?

Look after blood pressure, blood sugar, weight and smoking: these are the factors that predicted kidney decline after nephrectomy. To be honest about the evidence, no randomised trial has tested lifestyle advice specifically in people with one kidney after tumour surgery. What follows is good practice for kidney and heart health in general.

• Blood pressure. Measure it at home and treat it if it is high.
• Diabetes. Keep blood sugar within the range agreed with your doctor.
• Weight and smoking. Both were linked to reduced function in the Malcolm series. Stopping smoking also lowers cardiovascular risk.
• Salt. Moderate your salt intake, mainly because it helps blood pressure.
• Fluids. Drink to thirst and more in hot weather or during illness. There is no evidence that forcing large volumes protects the kidney.
• Protein. A normal balanced diet is fine. It is sensible to avoid very high protein diets and protein supplements; this is a precaution, not a trial result. If your eGFR is low, ask for dietary advice.
• Sport. Regular exercise is encouraged. Serious kidney injury in sport is uncommon, but there is no spare kidney, so collision and combat sports are worth discussing with your doctor before you return to them.
• Pregnancy. Data come from donors, not tumour patients. In the O'Keeffe meta-analysis, pre-eclampsia was more frequent in women who had donated (relative risk 2.12), at 5.9 events per 100 pregnancies, and few studies reported on pregnancy. Tell your obstetric team that you have one kidney.

Which medicines and tests need extra care with one kidney?

Tell every doctor, dentist and pharmacist that you have one kidney before a prescription or a scan. The points below are general statements, not results of trials in single-kidney patients.

• Anti-inflammatory painkillers (NSAIDs such as ibuprofen, diclofenac, naproxen). They can reduce blood flow within the kidney. Avoid regular use and ask which painkiller suits you.
• Contrast agents for CT and some MRI scans. Your eGFR is checked beforehand and the radiology team adapts the examination. Follow-up scans remain possible.
• Some antibiotics and other medicines cleared by the kidney. The dose may need to be lowered according to your eGFR.
• Herbal products and bodybuilding supplements. Their effect on the kidney is often unknown, so mention them.
• Vomiting, diarrhoea or fever. Dehydration strains the kidney, especially if you take blood pressure tablets or water tablets. Seek advice early.

What is kidney removal recovery like in the first weeks, and what if you travel for surgery?

Recovery from the operation itself usually takes a few weeks, and the blood test after surgery sets your new baseline. You are helped to walk soon after the operation. Tiredness and soreness around the incisions are normal at the beginning and ease gradually. Heavy lifting and strenuous sport are postponed for the period your surgeon specifies. A creatinine that is higher than before the operation is expected and usually settles at a new, stable level. Contact your doctor if you have fever, a wound that becomes red or leaks, much less urine than usual or new swelling of the legs.

Prof. Dr. Mutlu Ateş operates at Antalya American Hospital with the da Vinci Xi system.

For patients from abroad: your reports are reviewed first by WhatsApp or email, and the surgery day is set from the test results before the flight. The day before surgery you meet the surgeon, have the anaesthesia assessment and sign consent; the operation is the next day. Plan 5 to 7 days in Antalya in total. Before you travel, agree at home who will follow your kidney function (family doctor, urologist or nephrologist), and take home the discharge letter with your last creatinine and eGFR, the pathology report and the follow-up plan.

Which questions should you ask your surgeon?

Ask about your own starting point, because that decides more than the operation does.

• What are my eGFR and urine protein result now, before surgery?
• Can part of the kidney be kept, and if not, why?
• Is my other kidney normal on the scan?
• What eGFR do you expect for me after the operation?
• Do my diabetes or blood pressure medicines need to change?
• Which painkillers may I take afterwards, and which should I avoid?
• Who checks my kidney function at home, and when should a nephrologist be involved?
• What is my cancer follow-up schedule?

This article gives general information and does not replace an assessment of your own scans and results. Treatment is decided individually.