Chronic kidney disease (CKD) is a progressive condition that can ultimately lead to kidney failure, requiring kidney replacement therapy (KRT) in the form of dialysis or transplantation. However, in South Africa, access to these life-sustaining treatments is severely constrained in the public healthcare sector. For clinicians, this creates an ethical dilemma: how can limited resources be allocated fairly when the need for treatment far exceeds available capacity?

In his webinar, Who gets access? Ethical considerations in dialysis and kidney transplantation, Prof Davies, specialist nephrologist at Life Wilgeheuwel Hospital and Adjunct Professor in the Division of Nephrology at the University of the Witwatersrand, explored the complex clinical, socioeconomic and ethical considerations that determine who receives treatment — and who is excluded.

When scarcity determines survival

South Africa has a substantial burden of CKD, driven by conditions including hypertension, diabetes and HIV, alongside socioeconomic disadvantage, unequal access to healthcare and genetic susceptibility. These factors disproportionately affect Black South Africans, who are also more likely to depend on the public healthcare system for specialist kidney care.

Historical inequalities compound the problem. Prof Davies highlighted the limited expansion of public-sector dialysis facilities compared with the private sector, as well as the uneven geographical distribution of nephrologists and treatment centres. Patients living in rural and underserved areas may have to travel considerable distances to access specialist services.

The consequences are profound. Public-sector units must ration access to dialysis because they cannot accommodate everyone who needs it. Prof Davies presented data from academic centres showing that substantial proportions of patients with kidney failure are excluded from dialysis programmes and instead receive palliative care.

Many of these patients are relatively young, economically active and responsible for dependants. The ethical question is therefore not simply how to allocate limited resources, but whether a healthcare system can justify denying life-sustaining treatment to people who have no alternative means of accessing it.

Is transplant eligibility a fair criterion?

One approach used in the public sector is to prioritise patients considered eligible for kidney transplantation. This strategy has a practical rationale: transplantation generally offers better long-term survival and quality of life than ongoing dialysis, is more cost-effective over time and may enable patients to return to work. Transplantation can also free up scarce dialysis capacity for another patient.

However, Prof Davies highlighted a fundamental contradiction. South Africa's transplant rates are low and have declined over time. Transplant centres are also geographically concentrated, meaning that some patients may be considered eligible for transplantation in principle but have limited practical access to a transplant service.

Furthermore, there is no single, universally applied definition of transplant eligibility across all centres. Different selection criteria can produce different decisions about who qualifies for treatment.

The ethical concern is whether transplant eligibility remains a defensible basis for allocating dialysis when access to transplantation itself is restricted. A system intended to maximise benefit may inadvertently exclude patients because of circumstances beyond their control, rather than their individual clinical needs or likely treatment outcomes.

Age, HIV and BMI: when clinical criteria become ethical dilemmas

Prof Davies examined several criteria used in some patient-selection frameworks, including age, HIV status, body mass index (BMI) and socioeconomic circumstances. Although these factors may be considered when assessing transplant suitability, using them as rigid thresholds for access to dialysis raises important questions about fairness and discrimination.

Age is one example. Older patients may be perceived as less suitable transplant candidates, potentially placing them at a disadvantage when treatment is rationed according to transplant eligibility. However, Prof Davies noted that older people can benefit substantially from transplantation. In South Africa, grandparents may also play essential caregiving and economic roles within families, particularly in households affected by the HIV epidemic. Excluding an older person from treatment may therefore affect an entire family.

HIV status presents another ethical challenge. Given the high prevalence of HIV in South Africa, excluding people living with HIV could disproportionately disadvantage a substantial segment of the population. Prof Davies questioned whether this remains justifiable in the era of effective antiretroviral therapy, including dolutegravir-based regimens, which can achieve rapid viral suppression. HIV status alone should not automatically determine access without consideration of an individual's clinical circumstances and treatment prospects.

BMI is similarly contentious. Concerns about poorer transplant outcomes in patients with obesity may influence eligibility decisions. However, Prof Davies discussed evidence suggesting that higher BMI does not necessarily translate into poorer transplant outcomes and that patients with higher BMI may have better survival on dialysis in some studies. Using a fixed BMI threshold to exclude patients may therefore be difficult to justify when the evidence does not consistently support it.

The broader ethical principle is that selection criteria must be evidence-based, transparent and regularly reviewed. Rigid thresholds risk turning clinical characteristics into barriers to treatment without adequately considering individual circumstances.

Socioeconomic status and nationality: Whose lives count?

Socioeconomic status introduces another layer of complexity. Some selection frameworks consider whether patients are employed or able to attend dialysis regularly. While practical considerations, such as reliable access to treatment, matter, prioritising people according to their economic productivity risks penalising those already disadvantaged by poverty and unequal access to healthcare.

This creates a troubling circularity: Socioeconomic disadvantage contributes to CKD risk and progression, yet the same disadvantage may subsequently reduce a patient's chances of receiving treatment.

Prof Davies also explored access for foreign nationals. South Africa must balance constrained resources and the principle of national self-sufficiency in organ donation and transplantation with questions of human rights, fairness and the circumstances of individual patients. Some non-South African patients may be young, medically suitable for transplantation and actively contributing to society, yet face exclusion because of their nationality or immigration status.

The challenge is to develop clear, consistent policies that respect applicable legislation while ensuring that decisions are ethically defensible and do not rely on assumptions or prejudice.

Moving from rationing to equitable access

Prof Davies argued that rationing decisions must be explicit, transparent, uniform and ethically defensible. However, improving selection criteria alone will not resolve the underlying problem: insufficient treatment capacity.

Expanding public-sector dialysis facilities, training and retaining nephrologists, and improving access through rural and peri-urban outreach and satellite units are essential steps. Clear referral pathways are also needed so that patients can receive specialist care earlier, when interventions may slow CKD progression and reduce the need for kidney replacement therapy.

Finally, Prof Davies emphasised the importance of accountability. Strengthening the South African Renal Registry and publicly reporting who receives treatment, who is excluded and why would help identify inequities and assess the consequences of rationing.

The central message is that decisions about dialysis and transplantation are never merely administrative exercises. They determine who receives a chance to live. Clinicians must therefore advocate for fair allocation while recognising that genuine equity ultimately requires greater treatment capacity and earlier intervention. Prof Davies also urged healthcare professionals to screen patients living with hypertension, diabetes and HIV for CKD, helping to identify disease earlier and potentially reduce progression to kidney failure.

Conclusion

Prof Davies’ presentation highlighted the profound ethical dilemmas facing clinicians who must allocate scarce dialysis and kidney transplantation resources. While prioritising transplant eligibility may offer practical benefits, rigid criteria based on age, HIV status, BMI, socioeconomic circumstances or nationality risk perpetuating existing inequalities. Transparent, consistent and evidence-based allocation policies are essential, but they cannot replace the need to expand public-sector capacity and improve geographical access to care. Earlier diagnosis and intervention are equally important to slow CKD progression. Ultimately, equitable kidney care requires both fairer decisions and greater investment in services, ensuring that access to life-sustaining treatment is not determined by disadvantage.

To watch a replay of the webinar, click here https://event.webinarjam.com/9pqmp/replay/m26v2uz1ya239amgvfroqyn. Don’t forget to let John Woodford know that you watched the replay to earn your CEU. Send an email to john.woodford@media24.com. Include the name of the webinar, the date (24 August) and your MP number. If you are not registered with the HPCSA, you can request a certificate of attendance from John to submit to your council.