*Purpose: The 1-year mortality in children with end-stage kidney disease (ESKD) has been the highest among infants and toddlers. The objective of this study was to determine if kidney transplantation before 2 years of age was associated with a survival benefit for children with ESKD compared with remaining on the waitlist until older.

*Methods: Using the Scientific Registry of Transplant Recipients, we identified all deceased-donor kidney transplants performed in the United States before 2 years between 1987 and 2020. For each recipient, a comparison group was formed consisting of all candidates on the waitlist on the transplant date who were originally listed before age 2. Candidates on the waitlist who subsequently received a living donor transplant or were transplanted before age 2 were censored at the time of transplant. Patient survival was compared between transplanting before age 2 and remaining on the waitlist until older than 2 years using a sequential Cox regression model stratified by these comparison groups, and adjusted for age, gender, race, blood type, and dialysis. To account for non-proportional treatment hazards, time-dependent treatment coefficients were used covering 3 posttransplant follow-up periods: 0-3 months, 4-12months, and greater than 12months.

*Results: Our final analysis cohort included 354 deceased-donor recipients transplanted before age 2 years (cases) and 969 unique controls. The median age of cases at the onset of ESKD was 6 months (IQR: 1, 13) and the median age at transplant was 19 months (IQR: 16, 21). Compared with remaining on the waitlist, recipients transplanted before age 2 years had an increased risk for mortality during the first 3 months posttransplant (HR 2.9, 95% CI 1.6-5.4, p=0.0006), similar risk 4-12 months (HR 1.1, 0.59-2.1, p=0.76), and decreased risk beyond the first year (HR 0.31, 0.16-0.59, p=0.0004). In patients transplanted before 2 years of age, the most common known cause of death was infection (21%) and the most common cause of graft loss was graft thrombosis (61%).

*Conclusions: Despite the increased risk of mortality in the first 3 months posttransplant, kidney transplantation before 2 years of age is associated with a long-term survival benefit. Kidney transplantation in infants and toddlers should be considered at centers with an expertise on transplantation in this age group.

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