The true scale of the burden of end-stage kidney disease in sub-Saharan Africa is unknown, but may exceed that of high-income countries on the basis of the estimated prevalence of risk factors, especially hypertension. In this presentation I will review evidence relating to the underlying burden of end-stage kidney disease in sub-Saharan Africa and then consider the need for kidney transplantation, taking into account the likely costs and benefits from a health systems perspective. Demographic, epidemiological and economic shifts will have implications for the future incidence of end-stage kidney disease in the African region, and for the level of demand for treatment; the need for kidney transplantation will therefore continue to evolve. I will propose a research agenda that would support health policy and planning relating to the provision of renal replacement therapy in the region.