The Struggle for Optimization of Long-Term Outcomes After Kidney Transplantation.

I spite of improvement in organ preservation, immunosuppression agents, and reduced rejection rates, the long-term survival of kidney transplants has not changed over the past 20 years. The main goals of this issue of Advances in Chronic Kidney Disease are to discuss the current status of long-term kidney transplant outcomes, to analyze the main factors contributing to graft and patient survival rates, and to understand the ongoing diagnostic and therapeutic approaches to prolong kidney transplant longevity. The current status of patient and graft survival rates according to the most recent Scientific Registry of Transplant Recipient statistics has been nicely discussed by Israni and others in their article, comparing also, the American outcomes to those in Europe, Canada, and the Australian subcontinent. The survival differences in graft life and patient survival are discussed in the context of patient and donor mix and geographic distribution. Specific attention is also given to early outcome trends after the new kidney allocation system implementation in the USA. While kidney transplantation remains the treatment of choice in advanced kidney failure, there is still the dire need to efficiently manage the chronic kidney disease that patients are left with or have to deal with in the long run. Djamali and his associates discuss the differential rates of progression of chronic dysfunction in native and transplanted kidneys and the effect on metabolic and other nonmetabolic outcomes. In their review of immunosuppression minimization and avoidance protocols, Prashar and her colleague elaborate in detail the evolution of these protocols, the utility of these modalities of treatment in varying patient groups, and the pros and cons of their applicability in clinical practice. Avoiding injury is the mantra in the long-term management of the health of the kidney transplant. The article penned by Hricik, Vincenti and colleagues notes in two parts, the outcomes of trials testing efficacy and safety of costimulatory blockade or mTOR inhibitors to limit calcineurin inhibitor toxicity and prolonging the “life of the kidney.” Maggiore and Pascual have an elegantly written piece on cancer immunotherapy, using some checkpoint inhibitors with modulation in immunosuppression to successfully manage malignancy after transplantation, albeit