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When patients have end-stage organ failure, organ transplantation is often the best (and sometimes even the only) option. The shortage of donor organs remains a persistent global problem. As deceased donor organs are scarce, it is of great importance that available organs are used optimally. This thesis sheds light on the donation process and kidney utilization of deceased donor kidneys in the Netherlands, clinical decision-making in kidney offers for transplantation, long-term outcomes of kidney preservation methods, and finally it discusses the role of MRI in pre-transplant kidney quality assessment, and in identifying possible complications after transplantation. We concluded that 24% of deceased donor kidneys, that seemed medically suitable in the first place, were not transplanted. Furthermore, we objectified that kidney acceptance is very prone to subjective judgments by doctors, with little consensus on which suboptimal donor kidney should be transplanted or discarded. Finally, we developed a method to visualize intrarenal regional physiological and metabolic processes of a procured kidney on a pump, by several MRI techniques. To conclude, we provide suggestions to improve kidney utilization of deceased donors covering the entire donation cascade, starting during a potential donor’s treatment at the intensive care unit, via a complex sequence of events until eventual transplantation.