Organ shortage in liver transplantation has led the transplant community to expand the donor organ pool and reduce waiting list mortality by using so-called marginal donor or extended criteria donor (ECD) livers. The exact impact of these criteria on graft function and recipient survival are still under investigation. Most reports, however, show a clear correlation between organ quality and the posttransplant outcome. The role of ECD liver transplantation for severely ill recipients with high model for end stage liver disease (MELD) scores needs further clarification since transplant surgeons tend to allocate these grafts to more stable patients with lower MELD scores. Especially in the setting of ECD liver transplantation, strategies to improve graft quality and mitigate preservation and reperfusion injury may prove beneficial and play an important role in the future.