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