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. 2025 May 22:37:100597.
doi: 10.1016/j.lansea.2025.100597. eCollection 2025 Jun.

Analysis of kidney and liver exchange transplantation in India (2000-2025): a multicentre, retrospective cohort study

Vivek B Kute  1 , Himanshu V Patel  1 , Subho Banerjee  1 , Feroz Aziz  2   3 , Suraj M Godara  4 , Shyam B Bansal  5 , Anil K Bhalla  6 , Pranjal Modi  7 , Ashish Sharma  8 , Viswanath Billa  9 , Sajith Narayanan  2 , Priyadarshi Ranjan  10   11 , Manish Singla  12 , Arvinder S Soin  13 , Subhash Gupta  14 , Sandeep Guleria  15 , Prashant Bhangui  13 , Ankur Gupta  13 , Deepak S Ray  16 , Divyesh P Engineer  1 , Jamal Rizvi  7 , Vishal Parmar  1 , Madan M Bahadur  17 , Sarbpreet Singh  8 , Ashay P Shingare  17 , Bharat V Shah  18 , Benil Hafeeq  3 , Ismail N Aboobacker  3 , Shriganesh Barnela  19 , Munish Chauhan  12 , Santosh Varughese  20 , Dinesh Khullar  21 , Mohamed Rela  22 , Jatin Kothari  9 , Shrirang Bichu  9   23 , Dinesh Kumar  5 , Pratik Das  16 , Jyotish Chalil Gopinathan  2   3 , Jeethu Joseph Eapen  20 , Sushree Sashmita Das  16 , Sunil Prakash  24 , Anil Kumar Bt  25 , Shriniwas Ambike  26 , Ravi Angral  27 , Sanjiv Saxena  28 , Suhas Bavikar  29 , Vidyanand Tripathi  30 , Sanjay Srinivasa  31 , Umapati Hegde  32 , Vishwanath Siddini  33 , Nisith Mohanty  34 , Kim Jacob Mammen  35 , Abi Abraham M  36 , Divya Bajpai  37 , Sanshriti Chauhan  1 , Anil Kumar  38 , Manish R Balwani  39   40 , Hari Shankar Meshram  1 , Ravi Mohanka  41 , Surendran Sudhindran  42 , Gaurav Chaubal  43 , Thiagarajan Srinivasan  44 , Ashwin Rammohan  22 ; ISOT swap collaboration
Collaborators, Affiliations

Analysis of kidney and liver exchange transplantation in India (2000-2025): a multicentre, retrospective cohort study

Vivek B Kute et al. Lancet Reg Health Southeast Asia. .

Abstract

Background: In India, where deceased organ donation rates are relatively low, living donor transplantation programmes face challenges due to ABO incompatibility and sensitisation. Approximately one-third of healthy, willing living donors are incompatible with their intended recipients due to these factors. No large-scale data are currently available on kidney exchange (KE) or liver exchange (LE) transplants in low- and middle-income countries, including India.

Methods: We conducted a multicentre, retrospective cohort study including KE (2000-2024) from 65 centres and LE (2007-2025) from 7 centres across India. The living donors were near-related donors without altruistic and deceased donors. Demographic and clinical data of both donors and recipients were included in the study. The reasons for KE/LE, post-transplant outcomes with respect to patient and graft survival, rejection episodes, and donor outcomes were analysed. Kidney allocation system guidelines were: (i) Thorough pre-transplant work-up of DRP was completed before allocation to avoid chain collapse. (ii) A policy of non-anonymous allocation was practised (in contrast to anonymous allocation in high-income countries), where pairs can create a rapport during evaluation and surgery. (iii) Simple two-way exchanges, and simultaneous surgeries were considered for less experienced transplant centres in order to avoid donor renege.

Findings: A total of 1839 KE and 259 LE transplants were included in the study. The distribution of KE transplants included, 1594 (87%), 147 (8%), 44 (2%), 20 (1%), 24 (1%), and 10 (0.5%) transplants from 2-way, 3-way, 4-way, 5-way, 6-way and 10-way KE, respectively. Reasons for joining KE in transplanted pairs were ABO incompatibility 1610 (87%), compatible pairs 126 (7%), and sensitisation 103 (6%). There was notable gender imbalance, as more males were KE recipients 1504 (82%) and more females were donors 1469 (80%). The majority of LE were 2-way swaps (125 two-way vs. 3 three-way swaps), predominately involving male recipients (222 male vs. 37 females) and for ABO incompatibility.

Interpretation: Our largest-to-date cohort study supports that swap transplants are medically simple, but logistically complex. Access to KE or LE was unequally distributed and likely under-used. If replicated, our experience could increase access to transplants and help combat the looming threat of commercial transplants.

Funding: None.

Keywords: Deceased donation; Liver transplantation; Living donor kidney transplantation; Nonanonymity.

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Conflict of interest statement

We declare no competing interests.

Figures

None
Graphical abstract
Fig. 1
Fig. 1
Map of India showing the number of participating centres in the study.
Fig. 2
Fig. 2
Map of Indian showing the number of kidney exchange transplants across the nation.
Fig. 3
Fig. 3
Shows the year-wise gender of kidney exchange a) donors and b) recipients from 2000 to 2024.
See this image and copyright information in PMC

References

    1. Bello A.K., Okpechi I.G., Levin A., et al. An update on the global disparities in kidney disease burden and care across world countries and regions. Lancet Glob Health. 2024;12(3):e382–e395. - PubMed
    1. Mudiayi D., Shojai S., Okpechi I., et al. Global estimates of capacity for kidney transplantation in world countries and regions. Transplantation. 2022;106(6):1113–1122. - PMC - PubMed
    1. The Lancet Regional Health-Southeast Asia Organ transplantation in India: needs a bigger push. Lancet Reg Health Southeast Asia. 2024;21 - PMC - PubMed
    1. Kute V.B., Meshram H.S., Mahillo B., Domínguez-Gil B. Current status, challenges, and opportunities of organ donation and transplantation in India. Transplantation. 2023;107(6):1213–1218. - PubMed
    1. https://notto.mohfw.gov.in/WriteReadData/Portal/News/806_1_data_2022.pdf

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