Kidney transplantation--new developments.

The standard of care for patients with end-stage renal disease is kidney transplantation, which not only confers a survival benefit compared to hemodialysis, but is also cost-effective. The indications, contraindications as well as the preoperative assessment of recipients are discussed. The recurrence rate of the underlying renal disease has to be taken into account, especially in living donation. Growing organ shortage has lead transplant surgeons to accept older, less healthy, and even non-heart-beating donors, with generally good results. Living-donation is safe for the donor, outcome is excellent and plays an increasing role today. It has surpassed the number of cadaveric kidney transplantations in some countries. Many centres now apply laparoscopic donor nephrectomy with low morbidity. Matching for ABO blood group and HLA is routinely performed, as well as pre-transplant crossmatching. The surgical procedure has been standardized and the complication rate is low. Immunosuppressive protocols have evolved over time, and while the optimal regimen has not been defined, the availability of numerous agents allows the regimen to be individualized. New agents are being introduced into clinical practice. With increasing long-term graft survival and thus life-long immunosuppression, cardiovascular disease, de-novo malignancies and infectious complications are major causes of morbidity and mortality of transplant recipients. Effective prophylactic measures are often available, and surveillance protocols are warranted in these patients. Overall, the outcome of renal transplantation is excellent and has improved over time. Future prospects include induction of allograft tolerance, tissue engineering and xenotransplantation.