*Purpose: Over the past decades, immunosuppression regimen protocols, surgical techniques, and outcomes in pediatric kidney transplants (PKT) have evolved. This study describes our center’s experience in PKT from inception.

*Methods: We reviewed data of all 294 pediatric patients (age <18 at time of transplant) who underwent solitary kidney transplants at our center between August 1967 and October 2020 (Table 1). We compared transplant characteristics and outcomes in three distinct eras: early (1967-1993), intermediate (1994-2001), and modern (2002-2020). The modern era corresponds to the implementation of protocol biopsies.

*Results: The median age at time of transplantation was 14.0 years (IQR 9.25, 16.0). Obstructive uropathy was the primary cause of kidney failure (34%), followed by glomerular disease (22%). Median follow-up time was 11.0 years (IQR 5.60, 24.5), 14.0 years (IQR 6.50, 21.8), and 8.24 years (IQR 4.23, 12.8) for each of the three eras. One-year death-censored graft survival has improved from 89% to 93% and 95% across the three eras. The primary cause of 1-year graft loss was acute rejection in the first two eras, whereas both recurrent disease and acute rejection contributed equally to 1-year graft loss in the last era. Five-year death-censored graft survival has also improved from 82% to 85% and 88% for each respective era. Graft survival improvement was significant between the first and third eras (Fig 1), and older donor age was a significant risk factor affecting graft survival (p=0.0074). Deceased donor transplantation encompassed 25% of transplants in the early era, compared to 16% in the intermediate era and up to 30% in the modern era.

*Conclusions: Outcomes of PKT have improved over time, with a significant effect of donor age on graft survival.

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