Recent data show that, despite a long period during which fewelderly patients in end-stage renal failure received grafts, thereare neither medical nor ethical grounds for avoiding kidneytransplantation, at least in those aged under 70 or even 75 years ofage. Units in which transplantation in older recipients is routine showa good survival of recipients, and comparable survival of grafts tothose placed in younger recipients. This equality of graft survival withage arises because, although death with a functioning graft is morecommon in the elderly (principally from cardiovascular disease andinfections, with malignant diseases becoming more important with time),graft losses from rejection are lower, and so overall outcomes aresimilar. Long-term patient survival is better, quality of life isimproved and treatment is cheaper than in comparable elderly patientsmaintained on hemodialysis or chronic ambulatory peritoneal dialysis. Interms of allocation to older recipients, this success presents majorpractical and ethical difficulties given the shortage of cadaver organs.Data do not support the idea of `age-matching' older or marginalkidneys to older recipients: like their younger counterparts, olderrecipients do better with organs from younger donors. Living donors canbe used successfully even in those over 70, and elderly living donorshave a place in the treatment of the elderly. The optimumimmunosuppressive regimes for elderly recipients have not beendetermined, given their poorer immune responsiveness and lower rejectionrates compared with younger individuals.