Kidney Transplantation

Kidney transplantation has achieved remarkable success over the last century, both technically and scientifically. Sophisticated immunosuppression protocols are now available for the vast majority of patients, rendering hyperacute rejection nearly obsolete, with remarkable improvements in rates of early T-cell-mediated rejection as well. Antimicrobial prophylaxis has advanced dramatically. The economic advantages of kidney transplantation over dialysis are more evident than ever, with transplantation costs falling and dialysis costs continuing to increase. However, long-term graft survival remains suboptimal, due largely to inadequate control of the antibody response. Infection and cancer also remain as depressing clinical endpoints for some kidney recipients, and unacceptable rates of death-with-a-functioning-graft persist. Preemptive transplantation has not been adequately utilized, and limited organ availability continues to preclude many potential recipients from receiving transplants. Programs to create immunologic tolerance remain exciting, though currently limited to a few specialized centers. For these reasons, while many of the original promises of kidney transplantation have been met, significant promises in kidney transplantation remain unfulfilled and great needs remain for a future generation to address.