Kidney transplantation is the best treatment option for children with kidney failure. The key concepts of histocompatibility and immunological risk assessment determined for adults also apply to children. Pre-transplant immunological risk assessments must be performed for all children, according to current regional standards. Based on immunological risk, induction immunosuppression for pediatric transplant consists of either recombinant ATG-thymoglobulin or Interleukin 2 (IL2) receptor blockers along with pulse steroids. Maintenance immunosuppression protocols are similar to adults, typically consisting of a calcineurin inhibitor (CNI), mycophenalate mofetil (MMF), and oral low dose steroids. Drug metabolism is more variable in children, and often higher doses and sometimes three times a day administration of CNI are required to maintain adequate drugs levels in this age group. There is increasing interest in exploring steroid minimization protocols to avoid the serious steroid effects in children. However, avoidance or withdrawal of steroids is not standard of care and is acceptable only in a smaller sub-set of patients. HLA mismatch and the presence of DSA are the most significant risk factors for rejection in pediatric kidney transplant recipients. Pediatric transplant candidates require a careful assessment of their vaccination status. Ideally, all live virus vaccines should be administered at least 4 weeks prior to transplant. Children are more susceptible to opportunistic viral infections such as CMV and EBV and EBV-related PTLD if they are seronegative at the time of transplant and receive an organ from a seropositive donor. This risk increases when the intensity of immunosuppression increases and monitoring for CMV and EBV infection or disease is required. The adolescent age group is an independent risk factor for graft loss, likely due to the higher rates of non-adherence. Healthcare providers caring for adolescent and young adult transplant recipients must monitor adherence at every visit and follow a structured transition program to ensure that patients and their caregivers successfully cross-over to adult provider services. The goal of pediatric kidney transplantation is to address the key immunological challenges that this age group presents, aiming for maximal patient and graft survival.