Despite many achievements in renal transplant in the past few years regarding immunosuppression and tissue matching, the rates of early and late graft loss and return to dialysis are still high. Many of those with primary graft failure will be listed for a kidney retransplant, as this allows for better quality of life than dialysis. Many challenges face those requiring renal retransplant, including first graft nephrectomy and whether site of retransplant should be ipsilateral or contralateral, whether to conduct preemptive retransplant or wait while on dialysis, additional immunologic factors, immunosuppression after retransplant, cancer risk, BK virus infection, and retransplant in pediatrics. Despite the increased relative risks associated with retransplant, patients receive a significant survival benefit, better quality of life, and low health care costs versus remaining on dialysis after a failed transplant.