The burden of kidney failure remains largely underreported in East Africa. Health systems face numerous challenges, including lack of kidney registries, shortages of trained skilled healthcare workers, lack of diagnostic support, lack of equipment, and underdeveloped policies to govern provision of kidney failure treatment. Kidney transplantation, an effective treatment option against kidney failure, is underused mainly because of its cost and the lack of laws governing its provision. This paper discusses the salient issues affecting kidney donation, and transplantation in East Africa.