Pediatr Nephrol (2009) 24:475–484 current use of increasingly potent immunosuppression. Skin cancer is the most frequent, accounting for approxi- mately 60% of all cancers, but it does not contribute to mortality. Non-Hodgkin’s lymphoma represents about a quarter of cases and is the commonest cancer to cause death. Most patients do not present until they have been moved to adult units; by 25 years after first renal replacement therapy (RRT), the probability of developing a malignancy is 17%, with a peak incidence at 15 years [34]. In some children risk may be heightened by syndromes associated with a genetic predisposition to cancer. The overall mortality rate, if Epstein–Barr virus (EBV)-driven post-transplantation lymphoproliferative dis- ease (PTLD) is included, is 20%, and is associated with a 20% risk of graft failure [35]. Two other important factors that contribute to death are non-concordance with medications, or treatment withdraw- al [1], and obesity [36]. Obese children aged 6 to 12 years had a higher risk of death than non-obese patients (adjusted relative risk 3.65 for LD; 2.94 for DD), and death was more likely to be as a result of cardiopulmonary disease (27% in obese children, 17% in non-obese children). Comparison of mortality after transplantation with mortality on dialysis All studies show a survival advantage for patients who receive transplants in comparison with those who undergo dialysis, be that peritoneal (PD) or haemodialysis (HD): the lifespan of a child on dialysis is 40–60 years less, and, for a child with a transplant, 20–25 years less, than that of age- and race-matched general populations [37]. Eighty percent of patients on HD, 83% of those on PD and 93% of those with a transplant survive 5 years, according to the latest (2006) United States Renal Data System (USRDS) data [3]. Mortality rates are seven-times higher in those who have been on dialysis for longer than they have had a transplant [38], and treatment with dialysis is associated with a risk more than four-times as high as for renal transplantation [4]. Most of the increased mortality in children on dialysis is due to CVD; indeed, prolonged stay on dialysis is the most important risk factor for CVD. USRDS data from 1990 to 1996 among patients who started ESRF therapy as children and had died before they were 30 years of age showed that transplant recipients had a 78% lower risk of cardiac death than did dialysis patients. The cardiac death rate among dialysis patients was approximately 21 per 1,000 patient- years, whereas after transplantation, values were under 2 per 1,000 patient-years [39]. CVD accounts for 57% of deaths of those on HD, 43% of those on PD and 30% of those with a transplant [4]. It might be expected, therefore, that patient survival after pre-emptive transplantation would be superior, although, 477 conceivably, this might be difficult to demonstrate, as, for many children, the period of dialysis is only short. Euro- transplant identified a superior survival at 6 years in patients who received pre-emptive LD kidneys in compar- ison to LD after dialysis, but no difference in those receiving DD kidneys [40]. The North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) showed that adolescents who had undergone pre-emptive transplan- tation had a better survival rate [41]. Effect of race US registries demonstrate poorer outcomes for Afro- Americans than for the white population. Most of this dif- ference can be accounted for by an increased incidence of cardiovascular deaths by approximately 1.6 times. Between 1990 and 1996, of patients who started RRT as children and had died before they were 30 years of age, the percentage of cardiac deaths was higher among black patients at all ages: 0–4 years, 36%; 5–9 years, 18%; 10–14 years, 35%; 15– 19 years, 22%; 20–30 years, 32%; white patients 18%, 12%, 17%, 14%, and 23%, respectively. Among black patients, cardiac deaths occurred in 11% of transplant recipients and 34% of dialysis patients, and, among white patients, 9% and 25%, respectively [3, 11, 39, 42]. Transplant survival Overall transplant survival Transplant survival has shown a steady increase over the years [1, 12, 16, 42]. The earliest transplants, prior to 1983, had only a 20% 10-year survival [1]. Over the next decade, following the introduction of ciclosporin, there was an improvement to 45% [1], and this percentage has continued to increase since, to as high as 95% at 10 years in one centre [12]. However, we are still seeing the effects of the early poor success rates: 25% of the early transplants failed at 5 years, yielding a projected half-life of 10 years. Given a median age at transplantation of 13 years, 50% of all current paediatric kidney recipients will need a second graft before the age of 25 years [11]. Overall 5-year transplant survival varies between 44% to 95% [1, 7–9, 12, 14, 18, 21, 23–26, 30] at 5 years, 23%–95% at 10 years [1, 7–9, 12, 21, 23–26, 30], 35% at 15 years [8] and 21–36% at 20 years [1, 6, 8]. Graft survival of repeat transplants has been reported as being equal to or slightly reduced that of first grafts [1, 43]. When DDs were used, graft survival rates at 1, 3 and 5 years were 79%, 69%, and 62%, compared with 74%, 60%, and 47%, respectively, for the repeat transplants; for LDs, they were 91%, 83%, and 76% compared to 86%, 78%, and 72%, respectively, for repeat transplants [43].