Despite the significant increase in live donor kidney transplantation over the past 20 years, the number of patients awaiting transplant continues to rise [6]. In order to expand the pool of available donors, all the fields of science related to the process of donation/transplantation have been the subject of renewed interest in the last decade. Particular attention has recently been focused on the importance of preservation of grafts, especially of those obtained from marginal donors. Hypothermia allows the cellular metabolism to adapt itself to the anoxy condition (at 4 °C, the metabolism decreases by about 95 %); the drop in the energy consumption is also associated with the reduction of the activity of hydrolytic enzymes (proteases, phospholipases, nucleases) which limits structural cellular damage to the graft. Even if no firm recommendations establish the optimum method of renal preservation [7], some recent reports advocate certain advantages in terms of reduced incidence of delayed graft function and 1-year graft survival of machine perfusion when compared with static cold storage [8–11]. Even if the results of recent studies appear not quite homogenous, there appears to be enough benefit associated with pulsate preservation to justify its continued use in routine clinical practice. A perfusion machine, measuring parameters such as renal resistances, may also offer a prognostic value that, in the near future, together with pathologic and clinical features could become part of the evaluation of the graft and contribute to the allocation process. Further adequately powered randomized studies are required in both heartbeating and non-heartbeating donors, standard criteria donor, and expanded criteria donors using standardized perfusion fluid, in order to estimate the real advantage in specific and homogenous subgroups of donors.