Chronic kidney disease (CKD) is an escalating public health crisis in South Africa, and urgent reforms are vital, writes a group of concerned specialists in SA Medical Journal, outlining a roadmap of proposals they believe are imperative to save lives, particularly within the government health sector.
They write that the intersecting burdens of communicable diseases, particularly HIV and TBs, and non-communicable diseases (NCDs), are further compounded by a genetic predisposition to kidney disease in black populations, notably through high-risk variants in the apolipoprotein L1 (APOL1) gene. These variants are strongly associated with non-diabetic kidney diseases, including HIV-associated nephropathy and focal segmental glomerulosclerosis.
Previously under-recognised, CKD is now acknowledged as one of the fastest-growing causes of death among NCDs worldwide, and the authors warn that it will continue to drive preventable morbidity, premature mortality and escalating costs unless the situation is tackled.
They write that although the public sector’s dialysis capacity has remained largely static since 1994, there has been a massive scale-up of private haemodialysis (HD) units over the same period, driven by market demand and private sector investment,.
HD is now the predominant form of kidney replacement therapy in the country, with its use in the private sector far exceeding that in the public sector, approaching rates seen in high-income countries.
Peritoneal dialysis (PD), while currently under-utilised and primarily offered within the public sector, presents a valuable opportunity as a more cost-effective modality, particularly given its lower staffing requirements and potential for decentralised care.
Since December 2022, notable provincial disparities in public sector dialysis prevalence have persisted across SA, with services largely concentrated in urban centres and more densely populated provinces. The Western Cape reported the highest prevalence at 165 per million population (pmp), followed by the Free State (94 pmp) and Northern Cape (77 pmp).
In contrast, provinces such as Mpumalanga (3 pmp), Limpopo (14 pmp) and North West (17 pmp) recorded the lowest prevalence rates.
Even after adjusting for demographic and clinical factors, patients from Northern Cape, Eastern Cape, Mpumalanga and the Free State experienced substantially higher mortality than those in the Western Cape.
Workforce shortages remain a critical bottleneck. SA has a national nephrologist-to-population ratio of just 2.5 pmp, well below the international benchmark of 8-10 pmp. Some provinces have no full-time nephrologists in the state sector.
While all nephrology training occurs in the public sector, many newly qualified nephrologists migrate to private practice because of limited posts, inadequate infrastructure and professional isolation in underserved regions, and without tackling these human resource constraints, efforts to expand dialysis services and improve CKD outcomes will remain severely hampered.
Compounding these limitations are regulatory and procurement deficiencies that undermine service quality and system co-ordination.
There is no national policy framework or standardised quality assurance system governing the operation of dialysis units, and the proliferation of small, unregulated dialysis centres, often lacking oversight, licensing and proper clinical governance. raises concerns about quality of care, equity and sustainability.
In addition, gaps in national procurement processes further compromise care delivery. Dialysis consumables are inconsistently included in national tender contracts, and frequent stockouts, expired supplies and procurement decisions, made without adequate clinical input, are common.
A comprehensive regulatory and procurement strategy aligned with clinical priorities and health system capacity is essential to ensure high-quality, equitable and sustainable kidney care.
Paediatric and adolescent challenges
Challenges are compounded in the paediatric population, with access to CKD care for this vulnerable group limited and underfunded.
Paediatric nephrology services remain under-developed, constrained by both inadequate infrastructure and a severe shortage of trained specialists. There are only 23 paediatric nephrologists nationwide, and no state-funded training posts are available to increase this number.
Moreover, specialists are mostly in Gauteng, the Western Cape and KwaZulu-Natal, leaving large geographical regions without paediatric nephrology care. This challenge is further compounded by a critical gap in adolescent care, which frequently falls between the mandates of paediatric and adult services.
In the state sector, children aged <13 years are managed in paediatric units, but new presentations from 13 are directed to adult services. Adolescents (13-21) are thus particularly vulnerable, with dialysis eligibility inconsistently applied and, in some provinces, access frequently denied.
At Groote Schuur Hospital, Cape Town, a transition clinic addresses this gap by following patients up to 25, yet nationally the absence of structured transition pathways and co-ordinated handover between services disrupts continuity of care.
Dedicated, multidisciplinary, age-appropriate models are urgently needed to ensure equitable kidney replacement therapy for young people across.
A parallel shortage of trained dialysis nurses, technologists, dieticians, social workers, counsellors and transplant co-ordinators further limits the quality and reach of services for all patients.
Options for treatment
Kidney transplantation is the best treatment for end-stage kidney disease in eligible patients, offering superior survival, better quality of life and greater cost-effectiveness than dialysis. Improving the deceased donation system holds great promise, but with SA’s donation rate still under 1.6 pmp, strategic interventions are urgently needed.
Standardised data monitoring, quality assurance and co-ordinated pathways, from donor identification to transplantation, are essential.
Primary care-level gaps
At primary care level, SA faces several inter-related challenges in addressing CKD and promoting equitable access to care. While blood tests are performed, abnormal results may go unrecognised or unaddressed.
Routine CKD screening is also not consistently implemented in many primary healthcare (PHC) clinics, leading to missed opportunities for early diagnosis and intervention. In addition, long waiting times for follow-up appointments, compounded by staff shortages and high patient volumes, often result in patients being turned away or lost to follow-up.
Existing chronic disease platforms, including those for HIV, diabetes and hypertension, are inconsistently integrated with kidney risk assessment and monitoring, leading to fragmented care. Postpartum follow-up is also suboptimal, particularly for women with hypertensive disorders of pregnancy, who are often lost to follow-up despite their increased risk for CKD.
Additionally, the absence of a national policy for antenatal ultrasound screening to detect congenital anomalies of the kidneys and urinary tract represents a missed opportunity to intervene early.
Registries
Registries are essential for effective planning, monitoring and resource allocation in kidney care. SA’s national renal registry, established in 1977, ceased operation in 1994.
It remained dormant until it was formally re-established in 2012. Since then, consistent annual reports have been published, including the last 2022 report, which marks the eleventh year of data release.
Despite this reinstatement, registry reporting remains incomplete in key areas, especially paediatrics and PD, and there is inadequate reporting in certain regions.
A roadmap for kidney care
SAA urgently requires a co-ordinated national kidney health strategy, including a roadmap developed via consultation with paediatric and adult nephrologists, dialysis nurses, clinical technologists, the NDoH and key stakeholders to address critical service gaps.
Our recommendations include integrating CKD screening and prevention into PHC; ensuring equitable access to all KRT modalities; strengthening human resources through investment in nephrology training and workforce development; and establishing clearly defined care pathways for paediatric and adolescent patients.
Enhancing access to both deceased and living donor kidney transplantation is also essential, and the plan calls for improved procurement systems, expanded dialysis infrastructure and the development of robust regulatory frameworks and national registry systems aligned with international best practices.
Early CKD detection and prevention are cost-effective and feasible at PHC level. Nurse-led pathways, supported by standardised screening and referral protocols, can enable timely identification and management of early kidney disease.
Integration of HIV care with NCD care pathways could assist in patient retention and flow. Access to kidney-protective therapies, including sodium glucose transport type 2 inhibitors, must be expanded through inclusion on the Essential Medicines List.
In parallel, sustained national awareness campaigns are needed to promote healthy lifestyles and improve community-level recognition of kidney disease.
Our recommendations provide a practical and contextually relevant roadmap to integrate kidney care into existing health system structures, strengthen prevention and broaden equitable access to dialysis and transplantation.
With co-ordinated implementation, sustained political commitment and meaningful collaboration with the NDoH and key partners, SA can lead regional transformation in kidney health.
Study details
A roadmap for kidney health for South Africa in the context of universal health coverage
N Wearne,¹ FCP Cert Neph (SA), PhD; Y Chothia,² FCP Cert Neph (SA), PhD; F Bisiwe,³ FCP Cert Neph (SA); B Cullis,⁴ MB ChB, MRCP; R Freercks,⁵ FCP Cert Neph (SA), MPhil; V Rekhviashvili,⁶ FCP Cert Neph (SA), PhD; S Wadee,⁶ FCP Cert Neph (SA); M Davies,⁷ FCP Cert Neph (SA), MMed (Int Med); N Diana,⁸ FCP Cert Neph (SA), MMed (Int Med); M McCulloch,⁹ FCPaed (SA), PhD; G Paget,⁸ FCP Cert Neph (SA); W G van Hougenhouck-Tulleken,10 FCP Cert Neph (SA); Z Barday,¹ MB ChB, FCP Cert Neph (SA); L Jacobs,11 NephN, MPA; D Thomson,12FCS Cert Critical Care; A Muranda,13 FCP (SA), MRCP Nephrol
1Division of Nephrology and Hypertension, Department of Medicine, Groote Schuur Hospital and University of Cape Town; 2Division of Nephrology, Department of Medicine, Tygerberg Hospital and Stellenbosch University; 3Division of Nephrology, Department of Internal Medicine, Faculty of Health Sciences, Universitas Academic Hospital and University of the Free State; 4Department of Medicine, Faculty of Health Sciences, University of Cape Town; 5Division of Nephrology and Hypertension, Department of Medicine, Livingstone Hospital and Nelson Mandela University, Gqeberha; 6WitsUniversity, Donald Gordon Medical Centre; 7Division of Nephrology, Department of Internal Medicine, University of the Witwatersrand; 8Division of Nephrology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand; 9Department of Paediatric Nephrology, Red Cross War Memorial Children’s Hospital and University of Cape Town; 10Division of Nephrology, Dr George Mukhari Academic Hospital and Sefako Makgatho Health Sciences University, Ga-Rankuwa; 11Ministerial Advisory Committee for Organ Transplantation, National Department of Health, Pretoria; 12Division of Critical Care, Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and the University of Cape Town; 13Division of Nephrology, Steve Biko Hospital and University of Pretoria.
Published in the SA Medical Journal in October 2025
Abstract
Chronic kidney disease (CKD) in South Africa is a growing public health crisis, driven by the intersecting burdens of HIV, TB, hypertension, diabetes and obesity.
In black populations, high-risk apolipoprotein L1 (APOL1) variants add a genetic predisposition to non-diabetic kidney diseases, compounding risk. Global recognition of CKD has recently advanced, marked by the 2025 WHO non-communicable disease resolution, which urges the integration of kidney care into national health strategies.
This resolution emphasises prevention, early detection and treatment, while strengthening primary healthcare and addressing social determinants of health, particularly in low-income countries. However, in SA, domestic capacity has not kept pace.
Public-sector dialysis slots have remained static since 1994, while the private sector has expanded rapidly, deepening inequities by province and income. In the public sector, dialysis is rationed to patients eligible for transplantation, yet transplant access is limited by organ shortages, logistical barriers and variable provincial resources.
Expanding deceased donation and implementing kidney paired donation (KPD) programmes are essential to increase transplant opportunities, particularly for incompatible donor-recipient pairs, and to improve equity in access. Children and adolescents face additional barriers, including limited age-specific pathways and the absence of structured transition to adult care.
Workforce shortages, inadequate regulatory oversight, inconsistent procurement processes and incomplete registry reporting undermine service quality, limit expansion and perpetuate inequities in access.
Without urgent reform, CKD will continue to drive preventable morbidity, premature mortality and escalating costs. Scaling equitable dialysis and transplantation services, integrating KPD and investing in prevention, workforce and infrastructure are critical to reversing current trends and fulfilling the WHO’s call for action.
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