Purpose of review: With a persisting organ shortage and constant high discard rates, there is an urgent need to optimize the outcome and allocation of marginal grafts.
Recent findings: The Eurotransplant Senior Program was established as an 'old-for-old' allocation system emphasizing on the importance of keeping ischemic times short when utilizing marginal grafts. In addition to refined allocation systems, brief cold ischemic times, novel preservation techniques, a careful assessment of organ quality the utilization of dual kidney transplantation and donation after cardiac death kidneys from elderly donors may all help to increase the supply for renal transplantation. Moreover, age-adapted immunosuppression, improved patient selection and preparation for transplantation may help in improving outcomes when using marginal kidneys.
Summary: There is a significant potential to increase the utilization of marginal grafts with reduced discard rates, an increased utilization of dual kidney transplantation and the application of novel preservation methods.