Since the first successful transplant of a kidney from one twin to another in 1954, renal transplantation has moved from being at the cutting edge to being a mature technology. Registry data show that the current survival rates for grafts from cadavers are around 88% and 60% at one and 10 years after transplantation, respectively, while comparable rates for grafts from living donors are in excess of 95% and 70% (fig 1). 1 3 These rates have shown steady improvements over the past 10 years, with the one year survival rates for grafts from cadavers and living donors improving by around 5% in that time. 1 3 One year patient survival after transplantation is steady at 95%, with 87% alive at five years. In the medium term (one to three years) after transplantation, clinical outcomes are now so good that it is difficult to improve the survival of the patients or the grafts. Rejection rates have fallen over the years, and rejection is now an uncommon cause of early loss of a graft.

Major issues that now need to be resolved include the inadequate supply of donor organs, the side effects of treatment, the epidemic of cardiovascular disease in patients who have received renal transplants, and equity of access to transplantation. This paper discusses the recent progress in the field of renal transplantation and considers what work is needed to tackle the current issues facing transplant specialists.