Renal transplantation continues to be the goal of therapy for children with end-stage renal disease. Patient age, primary renal disease, psychosocial status, living versus cadaver donor allograft, immunosuppressive therapy, urologic status, and maximization of growth and development must be considered in determining the optimal time for transplantation. Immunizations should be up to date, and the immune status of both the donor and the recipient with regard to Epstein Barr virus (EBV), cytomegalovirus (CMV), varicella, human immunodeficiency virus (HIV) and Hepatitis A, B, and C must be known. Prednisone; cyclosporine or tacrolimus; and mycophenolate mofetil or azathioprine remain the mainstays of immunosuppression. However, new therapies such as sirolimus are under investigation for use in pediatric renal transplantation. Induction therapies include T-cell antibodies as well as the more recent addition of interleukin-2 receptor blockers. Complications including infection, rejection, and malignancy continue to be problematic in pediatric renal transplantation. There continues to be a strong focus on optimizing growth and development after transplant. Although patient and graft survival have improved over time, outcomes in pediatric renal transplantation continue to lag behind those in adults.