The first patients to receive kidney transplants in the 1960s were 20-to 40-year-olds who had lost their renal function to glomerulonephritis. They had virtually no other comorbidities than kidney failure. This group was thought best suited to endure the morbidity and stress of transplantation surgery and immunosuppression. At the dawn of clinical renal transplantation, barely half the patients survived for over a year. Today, 40 years later, the average age of adult kidney recipients in many transplantation centers approaches 50 years, and among the leading transplantation diagnoses are diabetes mellitus and hypertensive nephrosclerosis. In 1999, of all recipients of cadaveric kidneys in the United States, 16.4% were aged 18 to 34 and 45.8% were aged 50 and older. In fact, 9% were aged 65 and older. 1

These changes have come about because of the convergence of demographic realities and scientific advances. The fastest growing age group on the dialysis rolls is those aged 60 and older. Today, the average age of newly dialyzed patients in the United States is 61; 45% are diabetic. 2 At the same time, there have been incremental and persistent improvements in outcomes for kidney transplant patients. These advances are largely because of the development of more potent yet selective immunosuppressive agents coupled with better prophylaxis and treatment of common posttransplantation infections. Today, 1-year mortality of 5% and graft loss of 10% or less are commonly achieved. 1 These improved outcomes have been accompanied by a shrinking incidence of acute allograft rejection, the treatment of which is directly related to posttransplantation morbidity. Such developments have created an insatiable demand for organs in all age groups that has outstripped the available donor organ supply. Currently, about 50,000 potential recipients wait for kidney transplants, and about 13,000 are performed (8,500 cadaveric and 4,500 live donor). 1