Historically, age has been considered to be a relative contraindication for organ donors. The use of elderly donors for liver transplantation remains controversial due to the fear of inferior outcome. According to United Network for Organ Sharing (UNOS) data, the proportion of older donors has been increasing annually. This study describes the short- and long-term outcomes for transplantation of elderly donor livers. Three hundred and seventy-four primary liver transplantations, which had been performed at the University of Virginia Health System from 7 February 1988 to 31 December 1998, were included. Graft survival, incidence of primary non-function, and hepatic artery thrombosis (HAT) after transplantation according to the different age groups of liver donors were analyzed. Cases were analyzed by donor age (group I, n = 106: aged < 20 yr; group II, n = 217: aged between 20 and 49 yr; group III, n = 51: aged > or =50 yr), and by donor age in comparison with recipient age (group IV, n = 65: recipients transplanted with organs from donors within 5 yr of their age; group V, n = 266: recipients from donors > 5 yr younger than their age; group VI, n = 43: recipients from donors > 5 yr older than their age). Group III or VI (group of advanced donor age) and group II or V (control group) were compared by age, gender, race, body weight, height, pre-transplantation cytomegalovirus (CMV) status of the recipients donors, cause of brain death of donors, total or warm ischemic time, ABO matching, and degree of human leucocyte antigen (HLA) mismatching. No significant difference in 5 yr graft survival was found between the groups by donor age (p = 0.604) and by donor age compared with recipient age (p = 0.567). Moreover, no significant differences in the incidence of primary non-function and HAT after transplantation were found between the groups by donor age and by donor age compared with recipient age. Older donors were more likely to be women and to have antibodies to CMV, as well as to have died by cerebrovascular causes. Race, body weight, height of both recipients and donors, total or warm ischemic time of grafts, ABO matching, and degree of HLA mismatching were not significantly different between the groups. We conclude from this study that advanced donor age is not a contraindication to liver transplantation if careful assessment of donors is made on a case-by-case basis. There is a need to maintain an open mind with regard to the use of livers from older donors due to the current situation of serious organ shortages.