*Purpose: During the last 6 decades, the science around kidney transplantation has evolved tremendously resulting in significant improvements in kidney allograft and patient survival. There has been path breaking advancements in the immunosuppressive regimens and the overall care of transplant patients in terms of pre-transplant cardiovascular workup, intraoperative anesthesia, intensive care, prevention, early detection and treatment of rejection and infectious complications. We studied patient and graft survival, and causes of graft loss for primary kidney transplant recipients over 6 decades.

*Methods: Between Jan 1, 1960 – Dec 31, 2019, 3298 living donor (LD) and 2292 deceased donor (DD) primary kidney transplants were done (Table 1). The data was stratified by decade and donor type. Actuarial patient and death-censored graft survival determined at 1, 3, 5 and 10 years were compared. Common causes of death with function (DwF) and death-censored graft loss were compared.

*Results: Overall patient survival and death-censored graft survival for both LD and DD kidney transplant recipients has improved over the last six decades (Table 1). For each decade, patient and death-censored graft survival for LD recipients are better than for DD recipients. DwF was responsible for ~50% graft loss at each interval (Table 2). For each decade, the 3 major causes of DwF were CVD, infection, and malignancy. “Chronic rejection” although decreasing, has been the most common cause of DD and LD graft loss every decade. Acute rejections and thrombosis have decreased; however, losses due to non-compliance with medications and transplant glomerulopathy has been increasing (Table 2).

*Conclusions: The overall effect of improvement in patient care and immunosuppression over the last six decades have resulted in significantly reduced rates of patient and graft loss for both deceased and living donor recipients. DwF and immune-mediated processes remain the most common causes of graft loss. Our data suggests that improving long-term outcomes requires effort to reduce both DwF and death-censored graft loss.

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