Renal transplantation is the best treatment for most patients with end-stage renal failure. It markedly improves quality of life and in some cases increases life expectancy. Advances in immunosuppression and other areas of practice have led to an incremental improvement in outcome; 1- and 5-yr graft survival after cadaveric renal transplantation is now around 90 and 70%, respectively. This success has led to increased demand for transplantation that cannot be met by cadaveric heart-beating donors, numbers of which have remained relatively static. Increasing use is now being made of kidneys from so-called "marginal" or "extended criteria" cadaveric donors and from non-heart-beating donors. More reliance is also being placed on living kidney donation, which accounts for around 25% of kidney transplants in the United Kingdom and 50% of transplants in the United States. Much effort in renal transplantation is now being directed toward improving long-term outcomes. This chapter provides an overview of these and other issues in renal transplantation, focusing on some of the topics of current interest.