Introduction: Renal replacement therapy (RRT) is poorly developed in low-middle-income countries (LMIC).  Of the children with end-stage kidney disease (ESKD), only <20% have dialysis access, and transplant rates are <5/pmp.  Pakistan is a low-income country where ~60% of the population resides in rural settings and >50% live below the poverty line < $2 a day.  The government expenditure on health is 1.2% of the gross domestic product (GDP).  In this backdrop of economic deprivation, a model of Community-Government Partnership was developed to fund dialysis and transplantation “Free of cost with life-long follow-up with medication.  This paper reports the outcome of pediatric kidney transplants from an LMIC in the last 30 years.    
Patients and Methods: In the period 1993-2022, 988 pediatric live-related kidney transplants were performed at our center and reported to the Collaborative Transplant Study (CTS) in Heidelberg, Germany.  Outcomes are divided into three ERAs (1993-2002), (2003-2011), and (2012-2022) primarily based on the availability of immunosuppression drugs.  Immunosuppression in ERA1: Cyclosporine (CyA)/Azathioprine (AZA)/Steroid, ERA2: Tacrolimus (TAC)/Mycophenolate Mofetil (MMF)/Steroid with ATG induction, ERA3: IL-2 antagonists.  All graft dysfunction was confirmed by renal biopsy.  Data was analyzed using SPSS version 22.0. 
Results: Between (1993-2022), 988 live-related pediatric transplants were performed at our center.  The mean age of recipients was 14.66±3.17 years (Range 2-18) (72% were males).  The mean age of donors was 36.56±9.0 (Range 18-61) (58% were females).  The causes of ESKD were unknown in 54.35%, primary glomerulopathies in 22.27%, and nephrocalcinosis/nephrolithiasis in 14.47%.  HLA matching showed zero mismatches in 15.4%, 1-2 mismatches in 43.9%, 3 mismatches in 35.8%, and 4-6 mismatches in 4.9%.  Induction by ATG or IL-2 was given in 11.5%, CYA/AZA/Steroid in 94.3%, and TAC/MMF/Steroid in 5.7%.  Acute rejection rates were 29% in ERA1, 21% in ERA2, and 15% in ERA3 (p<0.001).  One and 5-year graft survival in ERA1 was 93% and 83%, ERA2 96% and 93%, and ERA3 99% and 94% (p<0.001).  The main causes of graft loss were interstitial fibrosis tubular atrophy in 42% and acute rejection in 16% while 26% died with function graft.  The main causes of patient loss were infection in 63%, and cardiopulmonary in 28%.   
Conclusion: Our experience shows that pediatric transplantation can be successfully established and sustained in Low-Income Countries provided RRT is freely available in the public sector.  Better immunosuppression and infection control can give results similar to high-income countries.