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Objectives: To evaluate long‐term outcomes and risk factors for graft loss in pediatric kidney transplantation over a 30‐year period. Methods: We retrospectively assessed 400 consecutive kidney transplants carried out in 377 children during 1975–2009. Patients were stratified according to the immunosuppressive regimen (era 1: methylprednisolone and azathioprine; era 2: calcineurin inhibitor‐based therapy, including methylprednisolone and azathioprine or mizoribine; era 3: basiliximab induction therapy, including calcineurin inhibitors, methylprednisolone and mycophenolate mofetil). Results: The median age and bodyweight at transplantation were 9.7 years and 20.6 kg, respectively. In total, 364 (91.0%) children received a living related donor transplantation. The acute rejection rate within 1 year post‐transplant decreased significantly from 61.0% in era 1 to 14.5% in era 3 (P < 0.001). For transplant eras 1–3, 1‐year graft survival was 81%, 93% and 95%; 5‐year graft survival was 66%, 86% and 93%; and 10‐year graft survival was 47%, 79% and 89%, respectively. The overall 5‐, 10‐ and 20‐year patient survival rates were 96%, 93% and 88%, respectively. A Cox multivariate analysis identified cold ischemia time (hazard ratio 1.385, 95% confidence interval 1.251–1.603), acute rejection (hazard ratio 1.682, 95% confidence interval 1.547–3.842), re‐transplant (hazard ratio 2.680, 95% confidence interval 1.759–3.982) and donor type (hazard ratio 2.957, 95% confidence interval 1.754–4.691) as independent risk factors for graft loss at 10 years post‐transplant. Conclusions: The progress of immunosuppressive therapy has led to a low incidence of acute rejection and a high graft survival rate across 30 years of pediatric transplantation. [ABSTRACT FROM AUTHOR]