Over the past 20 years, children have benefited from major improvements in both technology and clinical management of dialysis. Morbidity during dialysis sessions has decreased with seizures being exceptional and hypotensive episodes rare. Pain and discomfort have been reduced with the use of chronic internal jugular venous catheters and anesthetic creams for fistula puncture. Non-invasive technologies to assess patient target dry weight and access flow can significantly reduce patient morbidity and health care costs. Mortality in paediatric and young adult patients on chronic hemodialysis is associated with multifactorial markers of nutrition, inflammation, anaemia and dialysis dose, which highlights the importance of multimodal intervention strategies besides adequate hemodialysis treatment as determined by Kt/V alone.