The role of extracorporeal membrane oxygenation (ECMO) in neonates with congenital anomalies of the kidney and urinary tract (CAKUT) remains one of the more contested frontiers at the intersection of neonatal critical care and pediatric nephrology. Historically, severe CAKUT—particularly when associated with pulmonary hypoplasia, oligohydramnios/anhydramnios, or syndromic comorbidities—is a contraindication to ECMO, except in cases when ECMO is utilized as a “bridge-to-therapy” or “bridge-to-decision” [1, 2]. This perspective is driven by concerns regarding poor survival, limited candidacy for definitive therapies such as transplantation, and the burdens of prolonged life-sustaining support. However, advances in neonatal intensive care, dialysis modalities, and transplant pathways are reshaping these assumptions.

In this issue of Pediatric Nephrology, Ahmed et al. present cross-sectional, web-based survey data demonstrating substantial intercenter variability in exclusion criteria and clinician comfort with ECMO for CAKUT [6]. While a thorough review of their work is encouraged, in summary, the primary goal of the survey is to describe current institutional practices, clinical thresholds, and multidisciplinary processes for determining ECMO candidacy in the CAKUT population. Respondents, primarily neonatologists (75/99, 76%), completed two sections, the first regarding general practice and the second including approach to hypothetical cases. Secondary outcomes included exclusion criteria, the use of prenatal and postnatal prognostic markers, pediatric nephrology involvement, and the integration of kidney support during ECMO.