Renal transplantation improves survival of patients with end-stage kidney disease (ESKD).1 However, there continues to be a disparity between availability of deceased donor kidneys and potential recipients. In Australia, acceptance of ESKD patients aged 70–74 years for renal replacement therapy increased from 390 per million population (pmp) in 2004, to 469 pmp in 2008.2 In addition, find more the proportion of potential recipients aged 65 years and

over awaiting renal transplantation has increased by 21% between 2005 to 2008.3,4 The Scientific Registry of Transplant Patients (SRTR; i.e. US transplant registry data) has recorded a similar increase of prevalent potential recipients aged ≥70 years on the deceased donor waiting

list, from 114 in 1990 to 2544 in 2004.5 Deceased donor rates in Australia have remained low at 11 donors pmp in 2009 (10 pmp in 2005), compared with 34 pmp in Spain, 24 pmp in the USA and 17 pmp in the UK.6,7 However, there has been an increase in acceptance of older donor kidneys in Australia, with the number of deceased donors aged ≥55 years increasing 1.8-fold between 2001–2003 to 2007–2009.7 Kidneys from older donors are associated with inferior graft outcomes including late graft loss, chronic allograft nephropathy and higher risk of cardiovascular mortality;8,9 this is partially offset by the reduction in mortality associated with reduced wait-list time. Between 2005 and 2009 in Australia, there was a 1.3-fold increase in the number of expanded criteria donors (ECD),7,14 defined as any Ulixertinib datasheet donor aged ≥60 years, or any donor aged 50–59 years, with two of the following three criteria: cerebrovascular accident (CVA) death, terminal creatinine > 133 µmol/L or hypertension.15 Although the concept of ECD focuses primarily on advanced donor age, other risk factors such as CVA, hypertension, diabetes and high serum creatinine are also taken into account.16,17 Gaber et al. reported an

increase in glomerulosclerosis with increasing donor age, which correlated with a similar increased risk of delayed graft almost function (DGF), graft loss and poorer graft function in kidneys transplanted from older donors.18 Multiple studies have demonstrated that recipients of ECD kidneys have better survival compared with potential recipients on the waiting list but long-term outcomes associated with ECD grafts remains unclear.19,20 In a retrospective study of 2845 French transplant recipients aged ≥60 years, ECD grafts were associated with poorer graft survival compared with non-ECD grafts.12 The difference in graft survival was 6.2% at 12 months and 14.2% at 5 years (adjusted relative risk of graft failure associated with ECD grafts compared with non-ECD grafts was 1.98, P < 0.01).