An "expanded" criteria donor (ECD) kidney is defi ned in the United States by the Organ Procurement and Transplantation Network (OPTN) as a kidney re-covered from a deceased donor of age 60 years or greater, or a donor between 50 and 59 years of age who meets at least two of the following criteria: a terminal pre-recovery serum creatinine >1.5 mg/dl, a cerebrovascular accident as the cause of death, or a history of hypertension. Kidneys transplanted from an ECD have a relative risk (RR) of allograft failure that is ≥70% greater than that of kidneys transplanted from an "ideal" reference group of non-hypertensive deceased donors between the ages of 10 and 39 years with a terminal serum creatinine of less than 1.5 mg/dl and death from a cause other than a cerebral vascular accident. Since the inception of the ECD allocation system in 2002 there has been a national ECD kidney discard rate of 40%, significantly higher than the 9% discard rate observed for SCD kidneys. Non-recovery of ECD kidneys or discard of recovered ECD kidneys would be justified if the observed outcome for such kidneys was dramatically poor; but with the exception of kidneys from donors aged 70 years or older and percent GS >20%, a recently completed study data did not reveal any significant association between those characteristics that appear to contribute to the decision to discard an ECD kidney and post-transplant outcomes. Therefore, practice as it relates to discard often appears to be unjustified by actual transplant outcomes. There is an expansion of donation at the cardiac death in the United States attributed to changing societal attitude and practices in the intensive care unit that are leading to withdrawal of futile treatment before a brain death determination is made. The consequence of these developments has been a reduction in the eligible deceased organ donors in the United States.