OBJECTIVES: To investigate the economic burden of post-renal transplantation including direct and indirect costs. METHODS:  A systematic review was conducted in electronic databases (Medline, Embase, Cochrane Library) using a search strategy focused on observational studies of economic burden  after renal transplantation in UK, France, Spain, Italy, Germany, Belgium, Netherlands, Sweden, Denmark, Norway, Finland, and reporting outcomes for 2005-2015 in English. RESULTS: Twelve studies met the inclusion criteria. The following outcomes were described: first-year costs (post-transplantation costs including transplantation costs); first-year follow-up costs (post-transplantation costs excluding transplantation costs); three-year costs (post-transplantation costs excluding transplantation costs) and lost labor productivity costs. Average costs per patient in the first-year post-transplantation including transplantation range from €38,313 (Euro2010, Spain) to €57,500 (Euro2010, Germany) and excluding transplantation from €9,852 (Euro2011, Spain) to £18,929 (GBP2009, UK) which is approximately €21,200. Hospital stay and medications were the main contributors to total cost per patient regardless of whether or not transplantation was included/excluded.  Consistently across countries, estimated costs for the first 3-years post-transplantation appear to decrease with improved glomerular filtration rate (GFR). In a three year period, reduced renal function was associated with higher overall costs with return to dialysis being the main cost driver post kidney transplantation. The most costly events were acute rejection and complications due to cytomegalovirus infection. Average annual costs per patient due to lost labor productivity were only reported for Spain and increased from €5,079 (2009) to €5,483 (2010).   Two studies addressed indirect costs, but one study demonstrated that transplant patients had higher rates of employment than hemodialysis patients.    CONCLUSIONS:  First-year direct medical costs of kidney transplantation are substantial and vary considerably between European countries. Post renal transplant costs decrease during the period where there is generally continued improvement in GFR.  However, graft loss  appeared to be the main cost driver post kidney transplantation.