The unfortunate fact that long-term renal allograft survival has not followed the gains made in short-term allograft survival has been documented repeatedly in the United States [1] and also worldwide [2]. Undoubtedly, large inclusive datasets are needed to document certain overarching trends. Some of the most accepted risk factors for poor outcomes after transplantation like prolonged pre-transplant dialysis time [3] and the use of expanded criteria donors [4] needed confirmatory analysis from large databases to quantify these effects. When in smaller datasets, risk factors that have been confirmed for larger populations are not evident, one of the two things might be happening. Either the local reality is different and the sampled population has different characteristics and treatments are possibly different than the overall population or there is inadequate power to adequately identify and quantify multiple risk factors at the same time. The authors of the paper and the staff of the Rogosin Institute are certainly to be congratulated for their excellent outcomes and the big progress their center has made [5]. Internal quality assessments are a key component to any program success. National trends might not be reflected in local populations and each center has to assess what works best in their local reality. Several centers have documented excellent local results despite the lack of national evidence of significant long-term progress.

An important component of long-term survival is adequate care delivery to renal transplant patients. When centers are able to follow their patients very closely throughout their lifetime, this could make a substantial difference in outcomes. It is in fact very possible that much of the longterm attrition in renal transplant outcomes in the United States is driven by lack of medication availability and specialized medical care in general. The complicated socioeco-