REVIEW Paediatric kidney transplantation in under-resourced regions—a panoramic view Arpana Iyengar 1 & M. I. McCulloch 2 Received: 19 April 2020 /Revised: 21 July 2020 /Accepted: 24 March 2021 # IPNA 2021 Abstract Kidney transplantation is the ideal choice of kidney replacement therapy in children as it offers a low risk of mortality and a better quality of life. A wide variance in the access to kidney replacement therapies exists across the world with only 21% of low- and low-middle income countries (LLMIC) undertaking kidney transplantation. Pediatric kidney transplantation rates in these under- resourced regions are reported to be as low as < 4 pmcp [per million child population]. A robust kidney failure care program forms the cornerstone of a transplant program. Even the smallest transplant program entails a multidisciplinary workforce and expertise besides ensuring family commitment towards long-term care and economic burden. In general, the short-term graft survival rates from under-resourced regions are comparable to most high-income countries (HIC) and the challenge lies in the long-term outcomes. This review focuses on specific issues relevant to kidney transplants in children in under-resourced regions by highlighting limitations in the capacity and health workforce, regulatory norms, medical issues, economic burden, factors beyond financial hardship and ethical considerations relevant to these regions. Finally, the perspective of strengthening transplant programs in these regions should factor in the bigger challenges that exist in achieving the health-related sustainable development goals by 2030. Keywords Paediatric kidney transplantation . Low middle-income countries . Under-resourced regions . Developing nations . Challenges . Barriers . Outcomes The ideal kidney replacement therapy The choice of kidney replacement therapy for children with kidney failure should ensure a lower risk of morbidity and mortality and provide a better quality of life. In this regard, kidney transplantation is the ideal choice of kidney replace- ment therapy in children [1, 2]. Globally, in recent times, improved patient and graft survival have been observed with pre-emptive transplantation [3, 4]. Despite known advantages of living donor transplantation, with nearly 80% of living donors being parents of the child, the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) reveals that only one third of paediatric transplants arise from a living-related donor (LRD) [5]. Deceased organ transplant is beneficial to children in specific situations and in addition provides an opportunity for a potential second transplant with an LRD [4, 6]. While the world is striving to achieve the sustainable developmental goals (SDG) by 2030, child health care has taken centre stage. Investment towards achieving this goal has been proposed to be highly cost-effective in the long term [7], providing the unique opportunity to highlight vari- ous issues concerning the care of a child with kidney failure needing transplantation in low-resource settings. Access to kidney transplantation Amongst 215 countries across the globe, there are 82 coun- tries which can be classified as low-middle- and low-income countries (LLMIC) [8]. These countries have a greater preva- lence of chronic kidney disease (CKD) and death due to CKD in younger individuals (including adolescents) compared to high-income countries (HIC) on the global disease burden analysis [9]. * Arpana Iyengar arpanaiyengar@gmail.com 1 Pediatric Nephrology, St John’s Medical College Hospital, Bangalore India 2 Pediatric Nephrology, Red Cross War Memorial Children’s Hospital, Cape Town South Africa Pediatric Nephrology https://doi.org/10.1007/s00467-021-05070-3