OBJECTIVE Transplantation of the elderly often invokes strong and sometimes passionate arguments both in support and in opposition. Age alone has not been an absolute contraindication to a life-sustaining organ transplant for several decades. A comprehensive evaluation of the risks associated with surgery and suppression of the immune system in this often comorbid population becomes the focus. Risk for the recipient, however, must continually be evaluated and frequently updated in the context of that for the donor. RESULTS Following careful and critical evaluation, elderly patients appreciate the increase in life expectancy and improvements in quality of life as demonstrated in their younger counterparts. The outcome of recipients receiving kidneys from living donors has demonstrated superior graft and patient survival compared to deceased donors. Careful monitoring of medication levels for prevention of rejection while avoiding over immunosuppression and infection is critical to ensure such benefit. CONCLUSIONS Transplantation of the elderly via living donation is not only justified but in the appropriately chosen patient, with informed consent of both donor and recipient, is ethically sound. The expectations of both parties must be clearly stated and donor safety must remain the top priority. Living donors must be fully cognizant of the potential risk both in patient and graft survival prior to making such a life-changing decision to donate.