From 1969 to 1981 blunt renal injuries were recorded in 219 children up to the age of 16 years. All children with renal laceration, rupture, or pedicle injury had associated injuries, and 76% of them had a laparotomy for intraabdominal injury. Conservative management of five severe renal injuries in children resulted in 40% having a delayed renal operation and a total renal loss in 40%. A review of the published series of conservative management of severe renal injuries in children shows a renal surgery rate of 17 to 70%, a renal loss rate of 5 to 40%, and a significant complication/renal surgery rate of 32 to 80%. If conservative management of severe renal injuries in the multiple-injured child is used then up to 70% will require a second operation for the renal injury in a critically ill child recovering from the first operation. The nephrectomy rate with immediate surgical management of 16 severe renal injuries was 11% with nine renal lacerations, 100% with four renal ruptures, and 33% with three pedicle injuries. Two (67%) of the three pedicle injuries had immediate vascular repair with salvage of the kidney. There was increased renal salvage, reduced morbidity, and no need for a second exploration with immediate surgical management of severe reual injuries.