Background: Although evidence suggests that end-stage renal disease is associated with poor limb salvage and patient survival after arterial revascularization, little is known about the effect of renal transplantation. We analyzed the outcome in patients with renal transplants who underwent infrainguinal bypass procedures. Methods: Data prospectively entered into our vascular registry were reviewed for all patients who underwent lower extremity bypass procedures from January 1, 1990, through January 31, 2002. Sixty patients were identified who had a functioning renal allograft at infrainguinal revascularization. Kaplan-Meier survival curves were generated for limb salvage, patency, and patient survival and were compared with the Mantel-Cox log- rank test. Results: Sixty patients (40 men, 20 women; mean age, 47.1 years) underwent 76 bypass procedures in 71 limbs. Preoperative demographic data included diabetes (59 of 60 patients, 98.3%), coronary artery disease (26 of 60 patients, 43.3%), and preoperative serum creatinine concentration (SCr) greater than 2.0 mg/dL (9 of 60 patients, 11.7%). Mean follow-up was 25.1 months. Overall major complication rate was 11.8%, and 30-day mortality rate was 1.3%. Survival was 93.3% at 1 year and 66.6% at 5 years. Limb salvage was 87% at 1 year and 78% at 5 years. Primary graft patency was 78% at 1 year and 44% at 5 years. Preoperative SCr less than or equal to 2.0 mg/dL was associated with improved overall patient survival (5-year survival, 73.4% vs 37.5%; P = .01, log-rank test). Limb salvage and patency rates were not significantly affected by preoperative SCr greater than 2.0 mg/dL. Conclusions: Lower extremity bypass can be performed safely and effectively in patients who have undergone renal transplantation. However, the importance of a well-functioning renal allograft at surgery is demonstrated by marked improvement in patient survival.