Due to the increased demand in transplantable organs, the gap between kidney graft and supply grows. The organ shortage continues despite the fact that surgeons have liberalized their acceptance criteria for suitable deceased donor organs, have exploited the use of ABO-incompatible and marginal ‘expanded criteria donors (ECD)’. However, kidneys from ECD donors come with their relative risk of graft failure of 1.7 compared with a reference group. Therefore, selection of kidneys from ECD donors remains extremely important to guarantee an adequate kidney function and graft survival for long-term. Some ECD donor kidneys are not accepted by many centers due to their extreme age and additional risk factors such as hypertension, diabetes mellitus of the donor. A comprehensive assessment of the ECD kidney is mandatory and long-term graft survival and kidney function need to be assured.