Modality, utilization and mortality in pediatric ESKD: a registry-based study

Introduction Pediatric end-stage renal disease (ESKD) is rare but clinically complex. This study evaluated modality utilization, transplant access, and mortality among pediatric ESKD patients in the IPRO Network registry. Methods We performed a retrospective registry-based analysis of 1,628 pediatric ESKD patients from four U.S. regions between 2018 and 2024. Descriptive statistics summarized patient characteristics and treatment patterns. Competing risk models were used to assess time to modality transition, transplant listing, transplantation, and survival. Results Pediatric patients represented 0.65% of all ESKD cases in the network. Peritoneal dialysis (PD) was the most common initial modality in children aged 0–2 years (72%), compared with 24% in those aged 15–17 years. Overall, 46% started hemodialysis (HD), 31% PD, and 23% were preemptively listed for transplantation. Transitions from HD to PD were uncommon. Transplant listing occurred in 63% of patients by 1 year and 81% by 3 years; transplantation occurred in 22% and 53%, respectively. One-, two-, and three-year mortality rates were 3.4%, 5.4%, and 6.6%, with the highest mortality rate in children aged 0–2 years (10% at 3 years). Discussion PD is the preferred initial modality in very young children, while older children more often start hemodialysis. Overall survival and transplant access were favorable, but infants and toddlers remained the most vulnerable subgroup. Conclusion Pediatric ESKD accounts for a small but distinct share of the ESKD population. Early transplant access and good short-term survival were observed, but outcomes remain poorest in the youngest children.