Our centre (not-for-profit, government unaided) is one of the few in India providing low-cost KRT to children. Nearly 50% of our ESKD patients remain on conservative treatment and only 20% achieve transplantation1. The pediatric nephrology team faces ethical dilemmas arising not only from financial hardship but broader systemic societal issues. We describe 3 cases with unique ethical dilemmas from among the records of pediatric ESKD patients. These are presented from a child-based as well as a broader systemic perspective. Case 1: A 5 year old boy with PUV progressed to ESKD. The well-educated, financially comfortable parents refused to consider dialysis or pre-emptive transplantation. Despite the child’s uremic symptoms, the parents continued to refuse dialysis, agreeing only to give him medicines. In high-income countries, when parents refuse dialysis, pediatric nephrologists can request social services to intervene. -these services are absent in India. Ethical Challenges: - Child-based perspective: Are we obligated to continue treating him, providing only conservative therapy when KRT is available?- Broader concern: In pediatric ESKD, who defines the right of the child to live? Are there limits to parental authority? Case 2: Both children of a poor family had FHHNC (autosomal recessive renal tubular disease progressing to CKD). The elder boy was in ESKD and his brother had already reached CKD stage 3 when they were diagnosed. The father (already in debt) could not afford to pay for dialysis for one son and medications for the other. Children do not have access to universal healthcare coverage (UHC) for KRT. The father asked us what he should do. Ethical Challenges:- Child-based perspective: Typical of our setting, decision making has been deferred to the healthcare team. Should pragmatic consideration of the family’s circumstances influence our education and recommendations?- Broader concern: How do we promote equitable access to affordable KRT for children in low resource settings? Case 3: An 11 year old boy with ESKD has been on dialysis for over 4 years without receiving a kidney transplant. He had no available living donors and was listed for a deceased donor transplant but with no calls. There is no national organ sharing network, and children are not prioritized in the state’s organ allocation policy. This leads to long wait times and accumulating costs. The child’s family is highly distressed from high out-of-pocket healthcare costs, the unrelenting burden of care and fractured family relationships. Ethical Challenges:- Child-based perspective: What solution can we offer this family?- Broader concern: Children are at a disadvantage when the approach to allocation is based on a f'irst-come-first-served' or a utilitarian approach (in a society where the value of an earning adult (often male) is placed above a child’s rights. Figure 1 Summarises these issues In caring for children with ESKD in a low resource setting our centre faces unique ethical challenges. These arise from issues of inequitable access to KRT (a global concern) but also from the value society places on the right of a child with a chronic disease to live.