In recent decades, the long-term survival rate of kidney allografts has increased. However, there is still an increasing number of recipients who receive the renewal therapy again due to allograft failure. In 2018, the number of patients waiting for a kidney transplant increased by 11%, and dialysis therapy was received in 1.1% of patients with failed graft. Kidney graft loss is an important cause of end stage renal disease. Patients with a failed kidney transplant have been shown to have a significant increase in mortality compared with patients with a functioning graft or patients initiating dialysis for the first time. In a study of 4,743 kidney transplant recipients in Canada, for example, the risk of death was significantly higher with allograft failure versus those with continued allograft function (adjusted hazard ratio [HR] 3.4, 95% CI 2.75-4.2). The risk for infectious complications, cardiovascular disease and malignancy is greater than in the dialysis population due to the frequent maintenance of low dose immunosuppression, which is required to reduce the risk of allosensitization, particularly in patients with the prospect of retransplantation from a living donor. One of the most important aspects of managing the patient with a failing kidney allograft is deciding when and how to safely stop maintenance immunosuppressive therapy. In addition, transplant nephrectomy can also be considered in the patients with a failed kidney transplant, and eventually, it is necessary to determine when to start maintenance dialysis. However, the management of these patients present several controversial opinions and clinical guidelines are lacking. This topic will review the medical and surgical management of patients with a failed kidney transplant.