Kidney transplantation is the treatment of choice for most patients with end-stage renal disease (ESRD), with success rates greater than were envisioned as recently as a decade ago. Unfortunately this trend has created unprecedented demand for transplantable organs and new challenges for those desiring transplantation. This report is an overview of this changing landscape, with a focus on the clinical implications of the current process that culminates in renal transplantation. It also highlights potential solutions to overcome these newly recognized obstacles.