Introduction: Resource and organ shortages in the developing world place a responsibility on transplant units to propose only suitable candidates for organ transplantation.^[1][2] The majority of our CKD 5 patients present for the first time undiagnosed and needing emergency acute dialysis. This results in patients being placed on dialysis before an adequate assessment of their suitability for transplantation can be made. Once stable on dialysis it is ethically difficult to withdraw dialysis from children subsequently deemed unsuitable for a transplant. Also, prolonged dialysis due to long waiting times for an organ may result in patient deterioration past the point of suitability for transplant.^[3] 16/23 (70%) of our patients currently on dialysis are not on the deceased donor list. We set out to analyse the reasons why.

Materials and methods: A retrospective record review was performed on all 23 patients currently dialysed by the unit as at 1 October 2014.

Results and Discussion: 23 patients were on dialysis on October 1, 2014. The mean age was 14 years, 11 months (5y – 28y,4m), with a male to female ratio of 1.5:1. 15/23 (65%) were on HD, 8/23 (35%) were on PD (5 APD; 3 CAPD). The commonest primary diagnoses were FSGS and PUV, 13% (3/23) each. The mean duration on dialysis was 3 years, 10 months (4m – 14y,6m). 4/23 patients were still undergoing assessment for suitability to the transplant program and were therefore excluded from the study. Of the 19 patients included in the study 7/19 (37%) were on the transplant list. 6/19 (31.5%) had never been presented for DD listing due to social problems; these reasons included adherence issues (4/6), religious reasons (1/6) and misrepresentation of nationality (1/6). The remaining 6/19 had been previously listed but were now suspended from the list; these reasons included inadequate vascular access (4/6), myocardial dysfunction (1/6), and >3 prior transplants (1/6). The average age of the group who had been excluded due to inadequate vascular access was 19 years (16-28y) and their average duration on dialysis was 7 years. Social problems (6/12) and inadequate vascular access (4/12) were the most common reasons for exclusion from the list

Conclusion: Social problems resulting in poor compliance often only manifest once dialysis is well established emphasising the need for better early detection of paediatric CKD in South Africa. Shortage of DD organs results in markedly prolonged waiting times on HD with ultimate suspension from the transplant list due to poor vascular access. In addition, the absence of slots in our adult unit for older paediatric patients who have been deemed unsuitable for transplantation results in patients well above the paediatric age group remaining inappropriately in our care. All the above highlights the need for a dedicated transplant unit social service currently unavailable to our unit.