In the absence of national registries, no reliable data are available on the incidence and prevalence of end-stage renal disease (ESRD) in India and Pakistan. The incidence of ESRD is likely to be higher than that reported from the developed world, with chronic glomerulonephritis being the most common cause, accounting for more than one third of patients, while diabetic nephropathy accounts for about one fourth of all patients in India. Patients are generally younger (mean age 42 years) at the time of detection of ESRD and two-thirds first see a nephrologist after they have reached end stage. Treatment of ESRD is a low priority for the cash-strapped public hospitals and in the absence of health insurance plans, less than 10% of all patients receive any kind of renal replacement therapy. The vast majority of patients starting hemodialysis die or stop treatment because of cost constraints within the first three months, and less than 2% patients are started on ambulatory peritoneal dialysis. Although renal transplantation is the cheapest option, only about 5% of all patients with ESRD end up having a transplant. Living related donor transplants constitute 30 to 40% of all transplants in India, but there is a conspicuous gender bias with female donors donating kidneys for their male relatives. Cadaveric transplantation has yet to pick up and accounts for less than 2% of all transplants. The enactment of legislation to regulate renal transplantation in India has not been able to prevent unrelated (paid) donor transplants, which constitute 60 to 70% of all renal transplants. Cyclosporine, azathioprine and prednisolone continue to be the backbone of post-transplant immunosuppression, with cyclosporine being stopped in a significant proportion at one year post-transplant to cut down costs. Increasing awareness of renal disease amongst the population and general practitioners could result in early diagnosis of chronic renal failure and give opportunity for preventive strategies to delay the onset of ESRD. Preemptive transplantation and use of generic cyclosporine can help bring down the costs of treatment. Innovative and affordable health insurance policies can also increase the number of patients who receive effective treatment for ESRD in these two countries.