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In the absence of malignancy or other severe co-morbidity, kidney transplantation offers better survival rates and quality of life than dialysis. Despite this survival advantage, many lower and upper middle-income countries do not offer adequate kidney transplant services. This is particularly troubling as end stage kidney disease is often more common in these countries than in high-income countries and overall is less costly in the life of a patient. We describe the contrasting levels of provision of kidney transplantation in Mexico, India, Nigeria and Ghana and Zimbabwe and kidney transplant services for children in Africa.