Abstract: Recipient age at transplant is an important predictor of outcome. The age most commonly associated with increased risk is infancy. An important, but less recognized, age group at high risk is the adolescent. We analyzed the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) database to determine the patient and graft outcomes of adolescents (13–17 yr of age) compared with younger children. The adolescent age group had a similar percentage patient survival rate compared to that of the younger age groups, except for the infants (0–1 yr), who had a dramatic drop-off in the early post-transplant period. Regarding the long-term graft survival for living donor recipients, adolescents had the poorest percentage graft survival compared to the other age groups, including the infants (p < 0.001). Among cadaver donor recipients, the adolescent group had a significantly poorer graft survival than the 2–5 yr and 6–12 yr age groups (p < 0.001). Although the infants had the poorest graft survival (p < 0.001), after the sharp drop-off in the immediate post-transplant period the slope of their graft-survival curve was similar to that of the 13–17 yr age group. The percentage of late acute rejection episodes among the 6–12 yr (26.0%) and 13–17 yr (22.2%) age groups was significantly higher than in the younger age groups (p < 0.001). The adolescents had relatively poor rejection reversal outcomes compared to the other age groups, with fewer complete rejection reversals and a greater number of partial reversals (p < 0.001). The increased risk of graft loss, late acute rejection, and incomplete rejection reversal observed in the adolescent age group demands further investigation. Lack of compliance with immunosuppression regimens may be an important contributory factor. Strategies to address the unique concerns of this high-risk population will be essential to improve outcomes.