HE long-term outcome of pediatric transplantation has shown vast changes over the last decade. Renal transplantation in children in particular has gone through dramatic improvements, especially as they have been related to the management and preparation of this particular group of recipients. This has been contributed to in no small manner by the development and use of new immunosuppressive agents. 1 Survival studies carried out by the European Dialysis and Transplant Association (EDTA) 2,3 and the North American Paediatric Renal Transplant Co-operative study (NAPRTCS) 4,5 and some major centers show graft survival of 80% at 3 years and most centers achieve 75% at 5 years. While the immediate and short-term outcome is dependent on complications such as vascular thrombosis and acute rejection, the long-term outcomes are related to immunosuppressioninduced complications and other related medical problems such as hypertension, hyperlipidemia, and diabetes. The factors affecting outcome of transplantation are: source of donor, age of donor and recipient, matching, immunosuppression, original pathology, and center effect. In children it is important to note that a special problem is compliance. There is a striking difference in results when one looks at the donor source. Live donors show early immediate function and a low rate of surgical complications. There are fewer rejection crises, and if rejection does occur better reversal is achieved. All results are therefore far superior with the live donor group. 6 Cadaver donors of pediatric recipients do tend to be smaller and thus lend themselves to more complications. The age of the recipient also has an impact on survival. Younger recipients show the poorest survival. Not only is this impacted upon by the vigorous immune system, technical problems in size mismatches may lead to further complications. 7,8 Recipients over the weight of 20 kg yield better outcomes. Differences are even more marked in recipients below the age of 1 year. If one then combines the effects of donor and recipient on each other, a live donor would produce the best results especially if the transplant is carried out in a recipient of over 20 kg. As in adult transplantation, HLA and DR matching is very important. 9 Not only is this crucial in obtaining early immediate survival, the long-term outcome is totally dependent on compatibility. The use of lower doses of immunosuppression because of good matching has an indirect effect on the long-term outcome. It is extremely important to consider the role of matching as poorly matched kidneys will lead to the production of high levels of antibodies. This may lead to considerable problems in obtaining further transplant for this group of patients who will require not only one but 2 or 3 transplants in a lifetime. An added benefit will of course be the reduction of acute rejection crisis in the first 3 months; as a consequence immunosuppression needs will be reduced. Immunosuppression is a double-edged sword, and while preventing rejection it can have disastrous effects on the immune system. The use of cyclosporin A and now FK 506 has had a marked effect on outcomes. 10 However, the side effects of these agents require consideration as they may lead to problems of cosmetic changes, which might induce noncompliance. Induction therapy with polyclonal or monoclonal antibodies will reverse early acute rejection and therefore prolong long-term graft and patient survival. It is, however, too early to comment on the use of agents such as mycophenolate mofetil and rapamycin. Recurrence of original pathology and de novo disease can affect long-term survival. Conditions such as focal sclerosis and mesangio capillary glomerulonephritis when they recur have an undoubted impact on the long-term survival. 11‐13 However, it is well known that the rate of deterioration of function varies between individuals and some conditions such as diabetic nephropathy will only show moderate decline in renal function. Oxalosis inevitably recurs in the transplanted kidney unless a liver is transplanted at the same time. Consideration should therefore be given to the original pathology in the selection and timing of pediatric transplants.