After 2 decades as a low‐cost transplant centre in India, our rates of kidney transplantation are low compared to the burden of end‐stage kidney disease (ESKD). We performed this study to identify possible barriers inhibiting paediatric kidney transplant and to assess the outcomes of paediatric ESKD. A retrospective chart review of ESKD patients (2013 ‐ 2018) at a tertiary paediatric nephrology centre was conducted. Medical/non‐medical barriers to transplant were noted. Patient outcomes were classified as “continued treatment,” “lost to follow‐up (LTFU)” or “died.” Of 155 ESKD patients (monthly income 218 USD [146, 365], 94% self‐pay), only 30 (19%) were transplanted (28 living donor). Sixty‐five (42%) were LTFU, 19 (12%) died, and 71 (46%) continued treatment. LTFU/death was associated with greater travel distance (300 km [60, 400] vs 110 km [20, 250] km, P < .0001) and lower monthly income (145 USD [101, 290] vs 290 USD [159, 681], P < .0001). Among those who continued treatment, 41 proceeded to transplant evaluation of whom 13 had no living donor and remained waitlisted for 27 months (15, 30). The remainder (n = 30) did not proceed to transplant due to unresolved medical issues (n = 10) or a lack of parental interest in pursuing transplant (n = 20). Barriers to transplantation in low‐resource setting begin in ESKD. LTFU resulted in withdrawal of care and was associated with low socioeconomic status. Among those who continued treatment, transplant rates were higher but medical challenges and negative attitudes towards transplant and organ donation occurred.

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