Transplant physicians in the United States continue to face an interesting problem when offering kidney transplantation as a form of renal replacement therapy to older end-stage renal disease (ESRD) patients. The limited life-expectancy of these patients and an ever-present shortage of cadaveric organs makes kidney transplantation in this population a potentially controversial issue. Early results suggested poor outcomes for cadaveric renal transplantation in middle-aged or elderly ESRD patients. Improved patient selection, changes in immunosuppression regimens, and living-related transplantation have increased the success of transplantation in these patients. Efforts to define older patients at risk for cardiovascular disease and to account for their altered immune function may further improve outcomes. However, if older ESRD patients are to be rightfully included in the patient population eligible for transplantation, then the organ shortage will inevitably worsen. A potentially intriguing solution to this problem is to expand the donor pool by including older donors. Despite data suggesting that recipients of older grafts may have shorter graft survival; older donors could readily serve as a source of kidneys for older recipients who do not require 20+ year graft survival based upon their projected lifespan. Ultimately, age alone should not serve as a contraindication to renal transplantation. In patients over the age of 60, 1-year patient and graft survival rates approach 85% and 75%, respectively. However, careful assessment of "biologic" age and comorbid illnesses should be considered when offering renal transplantation to older patients.