Renal transplantation among high-risk transplant recipients is becoming more and more common. As the incidence of end-stage renal disease is increasing the need for organ donors is also increasing, and with the shortage of organs the use of marginal donors has increased. All these factors impact patient and graft survival. As time has progressed the incidence of acute rejection has decreased significantly due to improvements in immunosuppressive medications. However, even though rates of acute rejection have decreased significantly overall patient and graft survival has not changed much over the years. In order to fully understand the stratification of “high-risk” renal transplantation many donor, recipient and allograft variables need to be considered.