[The evolution of kidney transplantation over the last 20 years].

Kidney transplantation is an efficient treatment of end stage renal disease, decreasing patient mortality by comparison with mortality in dialysis and improving patient quality of life. The number of patients living in France with a functioning transplant is almost as high as the number of patients on dialysis (33,000 versus 37,500 in 2009). The constant progress in immunosuppressive treatments has made graft survival improve. According to the "Agence de biomédecine", the national institution in charge of transplantation regulation and management, overall graft survival is 68% at 10 years but 80% for living donor transplantation. Transplantation indications have been extended with time to more difficult patients: retransplanted patients and elderly patients, to the point that age per se is no more a contraindication to transplantation. Increase in transplant activity has followed increase in kidney harvesting in marginal donors, called "extended criteria donors": older, hypertensive, having atherosclerotic pathologies. Kidney from these donors are attributed to recipients of similar age. With organ shortage, new sources of donors are proposed, non heart beating donors and living donors. Living donor transplantation is the best transplantation with the best results but it is insufficiently developed in France (8-10% of the total annual number of renal transplantations versus 30-50% in the Scandinavian and Anglo-Saxon countries). Extension of the definition of the living donor through the successive revisions of the Law of Bioethics should hopefully improved this situation.