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Pediatric en bloc kidneys are considered marginal for transplantation into adults. We aimed to compare the long-term outcomes of pediatric en bloc versus living donor kidney transplantation.A retrospective review was undertaken on pediatric en bloc and living donor kidney transplants performed at our center between 1990 and 2001. The outcomes compared between the groups included 25 year graft survival and longitudinal glomerular filtration rate.There were 72 pediatric en bloc and 75 living donor kidney recipients included in the analysis. Pediatric donors were 16.9 ± 11.2 months old and weighed 10.7 ± 3.8 kg with terminal serum creatinine of 0.50 ± 0.45 mg/dL. Living donors were 40.1 ± 9.4 years old and serum creatinine was 0.90 ± 0.16 mg/dL at the time of donation. En bloc kidney recipients had higher dialysis vintage (23.0 ± 29.2 months vs 14.3 ± 14.7 months; P = 0.03), and longer cold ischemia time (30.5 ± 9.8 hours vs 2.6 ± 0.9 hours, P < 0.001). Kaplan-Meier estimate revealed similar graft survival between the groups up to 27 years of follow up (log rank P = 0.78). Estimated glomerular filtration rate was significantly higher in pediatric en bloc kidney recipients from years 5 through 17 posttransplantation.Pediatric en bloc kidneys conferred long-term graft survival similar to living donor kidneys over a 25-year period after transplantation along with superior graft function. These findings support improved utilization of pediatric kidneys for transplantation into adults which not only helps to alleviate organ shortage but also provide excellent long-term function.