This article addresses some of the major epidemiological, clinical, financial and social issues related to the practice of renal transplantation in Egypt. It highlights the limited availability facing the tremendous need for this line of treatment. It provides an overview of the transplant activity in the country, with a brief description of the medical and surgical protocols generally adopted by most groups. As a representative sample, the results of treatment of the Cairo Kidney Centre are given, emphasizing the importance of local ecological factors in modifying the outcome, expressed as short and long term patient and graft survival. The effects of the high prevalence of 6 infective agents are described, including cytomegalovirus (CMV), hepatitis B and C viruses, salmonellosis, tuberculosis and schistosomiasis. Most of these agents are shown to influence the donor's selection while some may directly modify the graft outcome (CMV and salmonellosis), alter patient survival (CMV, hepatitis B) or necessitate changes in the surgical techniques or the doses of immunosuppressive drugs (schistosomiasis). The financial burden currently imposed on the state budget by renal replacement therapy in general, and transplantation in particular, is discussed. The circumstances leading to accepting live unrelated donors, and the subsequent reflections on the society are discussed. The stand of the Egyptian medical community against paid organ donation, its enforcement and outcome of its application are described.