Many children with ESRD reside far from a kidney transplant center. It is unknown whether this geographical barrier affects likelihood of transplantation. We used data from a national ESRD database. Patients = 18 yr old who started renal replacement in nine Canadian provinces during 1992-2007 were followed until death or last contact. Primary outcome was kidney transplantation (living or deceased donor). Distance between nearest pediatric transplant center and each patient's residence was categorized as: