Infants Face Highest Mortality in Pediatric Kidney Failure Registry Analysis

Children with end-stage renal disease account for only a tiny fraction of all kidney failure cases in the United States, but a new registry-based analysis shows that the youngest among them carry a markedly heavier burden than older children. The study, led by Angelika C. Gruessner and Subodh J. Saggi of Downstate Health Sciences University in Brooklyn and colleagues, examined dialysis modality choices, access to transplantation, and survival among pediatric patients captured in the IPRO Network registry. Its central finding is sobering: while overall survival and transplant access in the cohort were favorable, infants and toddlers aged zero to two years remained the most vulnerable subgroup, with a three-year mortality rate of roughly ten percent.

The researchers performed a retrospective analysis of 1,628 pediatric ESKD patients drawn from four U.S. regions between 2018 and 2024. Pediatric cases represented just 0.65 percent of all end-stage renal disease cases in the network, underscoring how rare kidney failure is in childhood even as it presents uniquely difficult clinical challenges. Because children can move between dialysis modalities, be added to the transplant waiting list, receive a transplant, or die over the course of follow-up, the team used competing risk models to assess the time to modality transition, transplant listing, transplantation, and survival.

Treatment patterns varied sharply by age. Peritoneal dialysis was the most common initial modality in children aged zero to two years, chosen for 72 percent of that group. Among adolescents aged 15 to 17, by contrast, only 24 percent began on peritoneal dialysis. Across the full cohort, 46 percent of children started hemodialysis, 31 percent began peritoneal dialysis, and 23 percent were preemptively listed for transplantation before ever starting dialysis. Transitions from hemodialysis to peritoneal dialysis were uncommon once initial treatment was underway, suggesting that the first modality a child receives tends to define their near-term course.

Transplant access emerged as a strength of the pediatric system. Within one year of ESKD onset, 63 percent of patients had been listed for transplantation, rising to 81 percent by three years. Actual transplantation occurred in 22 percent of patients at one year and 53 percent at three years. Preemptive listing, meaning placement on the waiting list before dialysis begins, applied to nearly a quarter of the cohort at baseline.

Survival figures were favorable in aggregate but uneven across age. One-, two-, and three-year mortality rates for the cohort were 3.4 percent, 5.4 percent, and 6.6 percent, respectively. The highest mortality was concentrated in children aged zero to two years, who reached a ten percent mortality rate at three years.

The authors conclude that pediatric ESKD represents a small but distinct share of the ESKD population, that early transplant access and good short-term survival were observed overall, and that peritoneal dialysis is the preferred initial modality in very young children while older children more often start hemodialysis. Outcomes, however, remain poorest in the youngest children.

The study’s registry-based design gives it a broad observational reach across four U.S. regions over six calendar years, but the authors frame their results as descriptive patterns rather than tests of clinical interventions. Descriptive statistics summarized patient characteristics and treatment patterns, while the competing risk models addressed how often and how quickly children moved to listing, transplantation, or death. As with any retrospective registry analysis, the findings describe associations and utilization within the network’s population during the study window rather than establishing causal effects of any particular modality on survival.

For clinicians and families navigating pediatric kidney failure, the data offer a quantified picture of what typically happens after diagnosis. Nearly half of children begin on hemodialysis, roughly a third start peritoneal dialysis, and nearly a quarter are listed for transplant without any dialysis at all. Within three years, most children are on the transplant waiting list and more than half have received a kidney, yet the mortality figures make clear that the benefits of this system are not distributed evenly across ages.

The concentration of risk in the zero-to-two age group stands out as the study’s most consequential observation. Infants and toddlers with ESKD reached a three-year mortality rate of ten percent, well above the cohort-wide figures of 5.4 percent at two years and 6.6 percent at three years. The authors’ conclusion is direct: early transplant access and good short-term survival were observed, but outcomes remain poorest in the youngest children, a reminder that infants and toddlers with kidney failure continue to face the steepest odds even within a system that delivers comparatively strong transplant access and survival for pediatric patients as a whole.

Subject of Research: Dialysis modality utilization, transplant access, and mortality in pediatric end-stage renal disease

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

Article References: Saggi, S. J., Mongia, A., Gruessner, A. C., Mallappallil, M., & Salifu, M. (2026). Modality, utilization and mortality in pediatric ESKD: a registry-based study. Frontiers in Nephrology, 6, Article 1930091. https://doi.org/10.3389/fneph.2026.1930091

Image Credits: AI Generated

DOI: 10.3389/fneph.2026.1930091

Keywords: pediatric ESKD, dialysis, peritoneal dialysis, hemodialysis, kidney transplantation, mortality, registry study, transplant listing, infants, end-stage renal disease, Modality, utilization