Has the survival of the graft improved after renal transplantation in an era of modern immunosuppression?

The introduction of new immunosuppressant drugs in recent years has allowed for a reduction in the acute rejection rate along with highly significant improvements in short-term renal transplantation results. Nonetheless, this improvement has not translated into such significant changes in the long-term results. In this way, late graft failure continues to be the frequent cause of readmission onto dialysis programmes and re-entry onto the waiting list. Multiple insults of immune and non-immune origin act together and lead to chronic graft dysfunction. The characteristics of the transplanted organ are a greater determinant of graft survival and although various algorithms have been designed as a way of understanding the risk of the transplant organ and thus assign the most adequate receptor, its clinical application still only occurs in exceptional circumstances. Meanwhile, characterising, for each patient, the immune factors (clinical and subclinical rejection, reactivation of dormant viral infections, adherence to treatment) and non-immune factors (hypertension, diabetes, anaemia, dyslipidaemia) that contribute to chronic graft dysfunction could allow us to intervene more effectively as a way of delaying the progress of such process. Therefore, identifying the causes of graft failure and its risk factors, applying predictive models and intervening in causal factors could constitute some of the strategies for improving renal transplantation results in terms of survival. This review analyses some of the evidences conditioning graft failure as well as related therapeutic and prognostic aspects: 1) magnitude of the problem and causes of graft failure; 2) identification of graft failure risk factors; 3) therapeutic strategies for reducing graft failure, and; 4) graft failure prediction.