Kidney transplantation (KT) is the therapy of choice for end-stage renal disease (ESRD). The ESRD population is aging and so are patients waiting for KT. New strategies have been made for increasing the donor and recipient pools, and as a consequence kidneys from older donors or donors with significant comorbidities, the so-called “expanded criteria donor” (ECD) kidneys, are used for transplantation. Although good outcomes have been achieved from ECD, several issues are still waiting for clarification and need to be discussed. The concept of age matching is accepted as a method to ameliorate utilization of these allografts, but an optimal and widely accepted strategy is still not defined. The development of machine perfusion and the dual kidney transplantation are techniques which further improve the outcome of transplants from ECD, but the described experiences are scarce or coming from small single institutional reports. Also due to age-related immune dysfunction and associated comorbidities, the elderly recipients are more susceptible to immunosuppression related complications (e.g., infections and malignancy), although a widely accepted and validated immunosuppressive regimen is still lacking. In this paper, we review the issues related to KT employing allografts from marginal donors with a particular interest for the elderly patients. 1. Introduction In the last two decades while kidney transplantation (KT) has been definitively recognized as the therapy of choice for end-stage renal disease (ESRD), the elderly population has progressively and largely increased over the years, all around the world [1]. At present there are two renal replacement therapies for ESRD: dialysis (including hemodialysis and peritoneal dialysis) and KT. The superiority of KT over dialysis is well established, warranting a better quality of life and an improved survival for all patients, including those with advanced age [2]. In the recent past, advanced age was considered by most to be a contraindication to KT, with advanced age of the donor also being among the most common reasons for discarding the offered kidneys [3]. The increasing disparity between the limited supply of cadaveric donors and the rising demand for kidneys has led to the consideration of alternative strategies to expand the availability of organs for transplant [4] as well as better ways of using the suitable allografts. Since the early 1990s the criteria for accepting kidneys for transplantation have been extended to allow the use of organs from “marginal donors” [5], and as a result the mean age of
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