Background Advances in immunosuppression, surgical techniques, and management of infections in children receiving kidney transplants have affected outcomes. Study Design We analyzed a prospectively maintained database of pediatric kidney transplantations. Results From June 1963 through October 2016, we performed 1,056 pediatric kidney transplantations. Of these, 129 were in children less than 2 years old. The most common indications for transplant were congenital anomalies (dysplastic kidneys), obstructive uropathy, and congenital nephrotic syndrome. Living donors constituted 721 (68%) of all donors. The graft and patient survival rates remarkably improved for both deceased and living donor recipients (p = 0.001). Currently, graft survival rates for deceased donor recipients are 92% at 1 year, 76% at 5 years, and 57% at 10 years post-transplant; for living donor recipients, 96% at 1 year, 85% at 5 years, and 78% at 10 years. The graft half-life was 19 years in deceased donor recipients, compared with 25 years in living donor recipients (p ≤ 0.001). Acute rejection was the most common cause of graft loss in the first year post-transplant. The following risk factors were associated with an increased risk of graft loss: deceased donor grafts (p = 0.0001), retransplant (p = 0.02), ages 11 to 18 years (p = 0.001) and pre-transplant urologic issues (p = 0.04). Living donor grafts (p ≤ 0.0001) and pre-emptive transplants (p = 0.02) were associated with decreased risks of graft loss. Conclusions The success rates of pediatric kidney transplants have significantly improved. Pre-emptive kidney transplantation with a living donor graft continues to be superior and should be the choice in children with end-stage renal disease.