The notable increase in organ donations and transplants in Italy in recent years has lead to the development of an atypical approach to kidney transplantation. All propitious considerations left aside regarding the organ donation rate which has placed Italy among the European leaders, a careful comparative evaluation of the data taken from Italian and international registries demonstrates that renal transplantations in Italy have not shared the same significant growth. The typology of the donors has influenced in a decisive way not only the number of renal transplantations, but also the access to transplant for some age groups and probably even the quality and cost. The overall view which emerges is complex and somewhat contradictory, but we believe that this perspective can furnish solid arguments for choices that need not to be delayed for the living donor transplant, the divulgence of a donation culture in the population, and the criteria for the allocation of the organs.