According to Japanese Society of Transplant, all recipients (living kidney + donated kidney) were investigated for their graft loss. Chronic rejection happened at any time, but the ratio was 61.3% between 1983 and 2000, 31.5% between 2001~2009, 24.2% between 2010 ~ 2019. This improvement due to avoid acute rejection by the development of immunosuppressive drugs and the established treatment for acute rejection. Such like chronic rejection is still problem for long standing graft outcome, Japanese government made a decision to measure anti HLA antibody and DSA after transplant covered with insurance since 2018. Based on protocol biopsy, we have challenged toward best practices for DSA positive chronic antibody mediated rejection as earlier opportunity as possible.  Accurate interpretation of renal allograft biopsy is necessary to guide therapy, especially when an episode biopsy is taken to rescue the graft. Contrarily, a protocol biopsy is carried out routinely to identify baseline conditions (biopsy at 0 or 1 h), subclinical rejection, and histological change under current immunosuppression regimen, drug nephrotoxicity, viral infection, and recurrence of glomerulonephritis. Semi quantitative scoring for active lesions including tubulitis, glomerulitis, capillaritis, arteritis, arteriopathy, and others such as polyomavirus infection are key factors in transplant pathology. We will show the data of protocol biopsy this time.  Recurrent glomerulonephritis is now 3rd cause of graft loss in Japan. In Asian countries, IgA nephropathy is most problem for long standing graft outcome.  We also show the data of tonsillectomy for recurrent IgAN in Japan. Non adherence in adult’s kidney transplant patients and CNI nephrotoxicity are also shown this KSN meeting.  About the graft survival rate, in the case of living kidney, the 5 year survival is 93.1% from 2010 to 2019. Mean transplant age is 49.8 yrs old for living donor transplantation and 48.1  yrs old for cadaveric. Over age of 50, malignancy is rising cause of graft and patients survival with caution in Japan.