Renal transplantation is the optimal treatment for children with ESRD. We undertook this study to establish the outcome of pediatric renal transplants in a resource-constrained environment in a developing country. A retrospective analysis on 90 pediatric renal transplants (age at transplant </=18 yr) done at our center over a 15 yr period was analyzed. The mean age of the recipients was 15 yr (range 6-18 yr) accounting for 6.1% of all the renal transplants done at our center (90/1472). Ninety-six percent of patients received kidneys from live-related donors. The major causes of ESRD were glomerulonephritis (28%) and urological abnormalities (17%), while the etiology was unknown in 50%. Immunosuppression was based on a triple drug regimen consisting of prednisolone, CsA and azathioprine in 98% of children. Amongst complications, any acute rejection episodes (46.7%), UTI (26.7%) and CMV disease (16.7%) predominated. The mean duration of follow-up was 42 +/- 33 month (range 3-159 month). Graft loss occurred in nine (10%) children at a mean duration of 25 +/- 22 month (range 6-70 month). Overall 1-, 5-, and 10-yr graft survival was 98%, 84% and 76%. Overall 1-, 5-, and 10-yr patient survival was 95%, 87%, and 79%. The significant predictors of graft loss were CMV disease (p = 0.018) and >2 rejection episodes (p = 0.05), while sepsis (p = 0.01) was the most important contributor to patient loss. Pediatric renal transplantation in India can be accomplished successfully. The graft and patient survival in our study, the largest from India, is comparable to those published from developed countries and is encouraging given the limited resources.