Improving long-term outcomes of kidney transplantation: The pressure is on.

Since the first successful operation in man in 1954, kidney transplantation has evolved from an experimental therapy to the treatment of choice for patients with end-stage renal disease (ESRD). Kidney transplantation offers a significant survival benefit to patients suffering from ESRD and improves their quality of life as compared with patients who remain dependent on dialysis. In children, kidney transplantation improves growth, cognitive performance, and psychosocial well-being. The number of transplantations performed each year in the Netherlands has continued to grow over the past decade and increased from 587 in 2002 to 960 in 2012. This expansion can largely be ascribed to the continuing success of programs for living kidney donation. Currently, in our country, more patients with former ESRD are being maintained with a functioning kidney transplant than with dialysis (9386 versus 6396 patients, respectively, on 1 January 2013). Kidney transplantation is, however, not a cure for ESRD. Kidney transplant recipients need medical follow-up and have to take immunosuppressive medication for life. Advances in immunosuppressive drug therapy have resulted in a dramatic decrease in the incidence of acute rejection over the past 30 years and have contributed to the substantial improvement of one-year kidney allograft survival which is now ≥90% in most transplant centres. Unfortunately, long-term transplantation outcome has not improved to a similar degree. Kidney allograft half-lives are approximately 9.5 years for deceased-donor kidney transplants and around 16 years for living-donor kidney transplants. Many transplanted patients will therefore at some point in their lives need a second transplant or return to dialysis. The causes of long-term kidney allograft loss are multifactorial. In about half of successfully operated patients, kidney transplants will fail because of diverse causes including, but not limited to, chronic rejection, late acute rejection (often related to non-adherence to immunosuppressive drug therapy), recurrent primary