Renal transplantation in children is now a well established mode of optimal therapy for children with end-stage renal disease. The cooperative endeavors of the pediatric renal transplant physicians in the USA and Canada have generated a large volume of data that lends itself to rigorous scientific analysis. With changing practice patterns, the percentage 1− and 2-year graft survivals for cadaveric donor pediatric renal transplants have increased to 83 and 78%, respectively, in 1991 compared with 72 and 65% in 1987. Craft failure from acute irreversible rejection continues to take its toll in children under the age of 6 years. With funding from the National Institutes of Health a major cooperative effort has been organized by the North American Pediatric Renal Transplant Cooperative Study to determine the mechanisms that lead to heightened immune response in young children. Surveillance biopsies done in the early post-transplant days will attempt to identify the molecular mediators of acute rejection. Rehabilitation of children will not be satisfactory without accelerated growth after transplantation. Unfortunately, the longitudinal studies of the natural histories of growth after transplantation demonstrates that catch up growth occurs only in a subset of young children and that for the majority of older children, intervention with recombinant growth hormone is necessary. However, concern regarding the potential of recombinant growth hormone to induce chronic rejection necessitates a controlled trial.