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J Am Soc Nephrol. 2015 Jan;26(1):20-9. doi: 10.1681/ASN.2014040378. Epub 2014 Aug 5.

Through a glass darkly: seeking clarity in preventing late kidney transplant failure.

Author information

  • 1Division of Transplant Surgery, Departments of Surgery and Immunology, von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota;
  • 2Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama;
  • 3Division of Nephrology and Hypertension, Department of Medicine, von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota; and.
  • 4Department of Surgery, University of Minnesota, Minneapolis, Minnesota.


A common lament is that long-term kidney transplant outcomes remain the same despite improvements in early graft survival. To be fair, progress has been made-in both our understanding of chronic injury and modestly, graft survival. However, we are still a long way from actually solving this important and difficult problem. In this review, we outline recent data supporting the existence of several causes of renal allograft loss, the incidences of which peak at different time points after transplantation. On the basis of this broadened concept of chronic renal allograft injury, we examine the challenges of clinical trial design in long-term studies, including the use of surrogate end points and biomarkers. Finally, we suggest a path forward that, ultimately, may improve long-term renal allograft survival.


chronic allograft failure; clinical trial; immunosuppression; kidney transplantation; renal transplantation; transplant pathology

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