This review is concerned with reappraisal of the implications of therapeutic procedures in patients with terminal renal failure. Renal osteodystrophy is a complex metabolic problem which re-emphasises the endocrine role of the kidney, as do anaemia and hypertension. Bilateral nephrectomy aggravates anaemia and possibly osteodystrophy, while providing only a partial solution to the problem of hypertension. Blood transfusion may give rise to cytotoxic antibodies in some patients, preventing renal transplantation. Management is further complicated by the different and often unpredictable rates of decline of renal function in various nephropathies. Careful evaluation of new therapeutic procedures is advocated.