Both dialysis and kidney transplantation are effective techniques for prolonging life in ESRD. Because dialysis therapy does not effect replacement of the metabolic functions of the kidney, it is less tha perfect. Successful transplantation that replaces all of the aspects of renal function is the treatment of choice. Successful transplantation is highly dependent upon the availability of a suitable donor and the appropriate tissue match, which remains a problem. Present immunosuppressive therapy required to prevent the immunoresponse causing rejection of the renal allograft is a tool too dull for the job. Since all immunoresponse is suppressed, infections are common, as are the multiple complications of cortical steroid therapy. For the dialysis patient, development of more compact effective dialysis apparatus and particularly the availability of replacement therapy hold promise. New approaches to diminishing the immune response to the graft without impairing that to microorganisms may well effect improvement in graft survival as will increasing knowledge of factors other than HLA antigens in the immunologic reaction. Development of an effective method for arresting the progress of glomerulonephritis before it reaches end-stage renal failure would obviate the necessity for dialysis or transplant therapy in appoximately two thirds of ESRD patients.