Renal transplantation is a relatively recent treatment option among the elderly with end-stage renal disease (ESRD). Since little is known regarding the clinical benefits of transplantation relative to dialysis in this age group, this study compares transplantation and dialysis among the elderly with respect to patient survival. Data utilized in this investigation were obtained from the Canadian Organ Replacement Register (CORR). The study population consisted of the 6400 patients aged 60 and over at registration, diagnosed between 1987 and 1993, for whom data on comorbid conditions were available. Survival probability, death rates, age-standardized mortality ratios (SMRs) and Cox regression analysis were employed to evaluate the survival experience among the transplant and dialysis groups. Transplant recipients were matched (by age, underlying diagnosis leading to ESRD, and number of comorbid conditions) to 2 randomly selected patients who did not undergo transplantation. Using Cox regression, the time-dependent hazard ratio for transplantation versus dialysis patients was estimated at 0.47 (P < 0.0001), indicating that even after adjusting for other known prognostic factors, elderly patients who received a transplant experienced significantly greater survival probability than those who remained on dialysis. When transplant patients were matched to randomly selected dialysis patients with the constraint that the corresponding dialysis patient have at least as much follow-up time as the transplant patient had waiting time, five-year survival rates were 81% and 51% for the transplant and dialysis groups, respectively (P < 0.0001). These results support the potential advantage of transplantation among the elderly, and may have important implications for renal care in this age group.