476 decisions regarding treatment of high-risk patients such as neonates and children with handicaps [15]. Some diagnoses are more common in particular ethnic backgrounds [2] or even countries (e.g. Finnish-type nephrotic syndrome), and patient and graft survival are affected by racial group [11]. Figures will also be affected by the proportion of LD, for which outcome is generally superior. Countries vary in the size of their LD programmes. Some centres use only LDs [16], whereas percentages differ considerably between both European countries and the USA. What is clear is that an increasing number of families are opting for LD, presum- ably as a result of information showing its superior results, at least over the first 5 years, the increasing understanding of the complications of dialysis, and the ability to plan the timing of the transplantation. For example, LDs provided 43% of all transplants in the USA between 1987 and 1991, 52% between 1987 and 2004, and, since 1998, have accounted for 58%. Of these donors, 82% were parents (56% mothers, 44% fathers) [17]. Patient survival The number of children on the waiting list for deceased donor (DD) transplantation has increased slowly over the past decade, despite an increasing proportion of LD. The mortality rate of children on the waiting list over the same time period has been low and has declined to 55 per 1000 at risk [18]. However, the overall mortality rate remains high, with a relative risk of death after transplantation that is 12.7-times higher than that of the age-related general population [1], with little sign of improvement since the 1980s [4, 19]. Although these values may be due to changing patient selection, they remain unacceptably high. Overall patient survival Overall 5-year patient survival varies between 70% and 100% at 5 years [1, 5–7, 9, 12, 13, 16, 18, 20–26], 75% to 95% at 10 years [1, 7, 9, 12, 18, 21, 23–26], 83% to 94% at 15 years [1, 27], 54% to 86% at 20 years [1, 5, 7] and there is one report of 81% 25-year patient survival [6]. Effect of recipient age Age is an important factor that has been demonstrated to affect patient survival, although there is evidence that its effect has declined in recent years. Several early reviews showed increased mortality in young children and, particularly, in those under 2 years of age at transplantation: in two studies there was a mortality rate of 21% [5, 28]; however, more recently, survival rates of over 98% have been reported [29, 30]. Increased risk of death was also seen to extend up to age 5 years at transplantation: Dutch data showed that the Pediatr Nephrol (2009) 24:475–484 mortality rate was nearly twice as high in those under 5 years of age than in those 6 to 10 years old [19]; in a review of children with an average age of 4.7 years who weighed <20 kg at transplantation, 19% were reported to have died [23]. A reduction in mortality rate has occurred in this age range too, with a halving of the mortality rate between the 1970s and 1980s in the Dutch report [19], a mortality rate of 8.2% unaffected by age less than or older than 5 years at transplantation [1], a 5-year survival rate of over 97% in under 6 year olds [31], a 91% 10-year survival rate in those weighing <15 kg [25], and 87% 15-year survival in those <11 kg at transplantation [32]. Most studies have small numbers of subjects, making statistics and interpretation difficult; however, what does seem to be the case is that deaths in those who had received transplants before they were 5 years old occur sooner after transplantation (indeed all the deaths in the younger age group were in those less than 15 years of age) than in those that had received transplants when they were over this age [1]. Effect of donor type All reports show a small but consistent benefit of LD on mortality at all ages up to 5 years after transplantation [1, 12, 13, 18]. However, thereafter, there are few long-term data available, with one centre showing a benefit [12] and one not [1] at 10 years after transplantation. The survival rate for recipients of LDs has been improving over time: in the USA it was 96.1% 5 years after transplantation, between 1995 and 2004, and was 94.7% between 1987 and 1994; for infants, 3-year survival rates have improved from 88.4% between 1987 and 1994 to 94.9% since 1995. LD has a particular benefit for the very young child: 5-year patient survival rates for recipients less than 2 years old was 86% following living related donation (LRD) and 70% following DD transplantation [17]. Causes of death after transplantation The major causes of death after transplantation are cardiovascular disease (CVD), infection and malignancy, variously reported as 30–36% for CVD, 24–56% for infection and 11–20% for malignancy [19, 21, 22, 27]. CVD has been defined in different ways, some studies including cerebrovascular events and arrhythmias as part of the definition. However, despite this, results are remarkably similar between centres, and, overall, CVD is the most common, and potentially preventable, cause of death. Infection, both sepsis related and due to opportunistic organisms, is becoming more of a problem with the use of more powerful immunosuppression. Malignancy is ten- times more common than expected for age [33, 34] and also might be expected to increase in incidence with