Patients aged 60 years and older represent the fastest-growing population with chronic kidney disease and end-stage renal disease (ESRD). In 2002, a total of 137,000 patients aged 65 years and older were on dialysis therapy in the United States, but only a highly selected minority of them (5%) were on the waiting list for a kidney transplant. The majority of older patients on dialysis therapy are not being referred for the waiting list, presumably because of comorbid diseases and lower life expectancy. However, kidney transplantation clearly has been shown to improve survival compared with dialysis, even for older patients. Because both patient age and time on the transplant waiting list increase the risk for death, older patients (ie, > or =60 years) who already have a shorter life expectancy than younger patients are more likely to die with a functioning graft. The limited supply of deceased-donor kidneys and increasing number of patients who would benefit from transplantation have created a dilemma about how to fairly allocate donor kidneys among patients of all ages while meeting the needs of the increasing number of older patients with ESRD. Although older dialysis patients receive fewer kidney transplants than younger patients, their patient and graft survival rates are good. Instead of applying rigid age limits, the "biological," rather than "chronological," age of individual patients should be assessed carefully to help clinicians select the most appropriate candidates for kidney transplantation and reduce morbidity and mortality in older transplant recipients.