Of 107 renal transplants, 25 patients who were restarted on dialysis due to graft failure were studied. Of these, 20 underwent renal transplant nephrectomy. Graft failure was due to a progressive functional loss in 18 (16.8%) and 4 other grafts were non-functioning from the outset. Of these 22 cases, 17 (77.2%) underwent transplant removal. Three (15%) viable grafts were removed, 2 due to urologic complications and 1 due to hemorrhage following percutaneous renal biopsy. A non-functioning renal graft was left in situ in 5 patients. Rejection was the most frequent cause of transplant nephrectomy (45%), followed by arterial thrombosis (25%) and infection (15%). Eighty-five percent of these procedures were performed before one year post-transplantation, usually 1-4 weeks after diagnosis. Only 3 (13.6%) of the 22 non-functioning grafts removed were viable for more than 12 months after transplantation. The surgical technique was subcapsular in 60% and classical in the remaining cases. This was the surgical approach in all emergency cases. Except for one postoperative death directly related with surgery, complications were observed in 10% of the cases. These did not present as being especially uncommonly severe. The estimated 10-year posttransplantation survival rates for patients and grafts were 87.4% and 62.9%, respectively. The clinical evidence for transplant nephrectomy correlated well with the histologic evidence from the surgical specimens relative to the diagnosis of acute rejection and vascular thrombosis, despite its clinical under-utilization, and were discordant for urinary fistula, chronic rejection and sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)