Since the 1950s, care for kidney transplant recipients in the United States has evolved around a model in which clinical management, quality metrics, and financial underpinnings are focused around the surgical procedure itself reflecting the concept that perioperative and short-term interventions are primary determinants of success. In the current era, short-term results are indeed excellent, but long-term success remains elusive for many. Emerging data, particularly a newfound understanding of donor-specific antibody and its consequences, now challenge the concept that late graft failure is the consequence of early events. Several major longitudinal studies, including the long-term Deterioration of Kidney Allograft Function (DeKAF) project and Clinical Trials in Organ Transplantation-09 (CTOT-09), highlight the primacy of later events in influencing long-term outcomes after kidney transplantation. Proper long-term care and monitoring of kidney recipients, with timely diagnosis and treatment of identifiable injury, offers the best prospect of improving long-term graft survival.