Cold ischemia triggers a cascade of noxious effects, which are amplified by restoration of blood supply reperfusion. These injuries generate inflammatory and immune responses that may potentially result in delayed graft function, enhanced alloimmune reactivity, and development of progressive pathological changes. Debout et al. outline the clinical importance of cold ischemia time in renal transplantation by demonstrating that each additional hour of cold ischemia can increase the risk of allograft failure and death.