The treatment of osteonecrosis in renal-transplant patients with hip arthroplasty was reviewed. From 1972 to 1988, the surgical treatment evolved from the use of cemented total hip arthroplasty (THA) to uncemented bipolar hemiarthroplasty to, most recently, porous-ingrowth THA. During this period, 46 patients had 77 hip arthroplasties. Cemented replacement was used in 32 hips, uncemented bipolar replacement in 32, and porous-ingrowth arthroplasty in 13. At the two- to 18-year follow-up evaluations, the average Harris hip rating was 89 points. Ratings averaged 82 points at 8.7 years in cemented hips, 91 points at six years in bipolar hips, and 90 points at 3.1 years in uncemented hips. Loosening occurred in 46% of hips with cemented total hip prostheses, 9% of hips with bipolar prostheses, and in no hips with porous-ingrowth components. Aseptic revision rates were 31%, 12.5%, and 0% respectively. Infection rates were 0%, 9%, and 10% respectively. Although the follow-up period was shorter for bipolar and uncemented THAs, uncemented bipolar hemiarthroplasty and porous-ingrowth THA may be reasonable alternatives for the renal-transplant patient with osteonecrosis rather than cemented THA, which has a high long-term failure rate. The early results of porous-coated hip arthroplasty are satisfactory in patients with a functioning renal transplant.