Children with kidney disease are at increased risk of having several comorbidities such as obesity, dyslipidemia, hypertension, and impaired glucose tolerance, and patients with a constellation of these symptoms are considered to have the MS. Children with kidney disease, and ESRD in particular, are at increased CV risk, as are patients with the MS. To determine the impact MS has on a particularly vulnerable population of children, those who have received a kidney transplant, Wilson et al. explored the prevalence of MS and the association of MS with cardiac abnormalities among this subset of children. They found an overall high prevalence of MS among pediatric transplant recipients and that the risk of left ventricular hypertrophy was higher among children with MS after renal transplant compared to those without MS. Review of the most common definitions of MS and also the clinical implications are discussed. While there is no doubt that children with kidney disease have a high prevalence of CV risk factors and that these children are at risk for CV events early in life, whether the sum of the parts of MS confers increased risk over what is seen with individual risk factors that often run together remains to be seen.