Kute Vivek B, Patel Himanshu V, Banerjee Subho, Aziz Feroz, Godara Suraj M, Bansal Shyam B, Bhalla Anil K, Modi Pranjal, Sharma Ashish, Billa Viswanath, Narayanan Sajith, Ranjan Priyadarshi, Singla Manish, Soin Arvinder S, Gupta Subhash, Guleria Sandeep, Bhangui Prashant, Gupta Ankur, Ray Deepak S, Engineer Divyesh P, Rizvi Jamal, Parmar Vishal, Bahadur Madan M, Singh Sarbpreet, Shingare Ashay P, Shah Bharat V, Hafeeq Benil, Aboobacker Ismail N, Barnela Shriganesh, Chauhan Munish, Varughese Santosh, Khullar Dinesh, Rela Mohamed, Kothari Jatin, Bichu Shrirang, Kumar Dinesh, Das Pratik, Gopinathan Jyotish Chalil, Eapen Jeethu Joseph, Das Sushree Sashmita, Prakash Sunil, Kumar Bt Anil, Ambike Shriniwas, Angral Ravi, Saxena Sanjiv, Bavikar Suhas, Tripathi Vidyanand, Srinivasa Sanjay, Hegde Umapati, Siddini Vishwanath, Mohanty Nisith, Mammen Kim Jacob, Abraham M Abi, Bajpai Divya, Chauhan Sanshriti, Kumar Anil, Balwani Manish R, Meshram Hari Shankar, Mohanka Ravi, Sudhindran Surendran, Chaubal Gaurav, Srinivasan Thiagarajan, Rammohan Ashwin
Department of Nephrology, Smt. G R Doshi and Smt. K M Mehta Institute of Kidney Diseases and Research Center, and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India.
Department of Nephrology, Aster MIMS Hospital, Kozhikode, Kerala, India.
Lancet Reg Health Southeast Asia. 2025 May 22;37:100597. doi: 10.1016/j.lansea.2025.100597. eCollection 2025 Jun.
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.
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.
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.
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.
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在印度，尸体器官捐献率相对较低，活体器官移植项目因ABO血型不相容和致敏而面临挑战。由于这些因素，约三分之一健康且愿意捐献的活体供体与预期受者血型不相容。目前在包括印度在内的低收入和中等收入国家，尚无关于肾交换（KE）或肝交换（LE）移植的大规模数据。
我们开展了一项多中心回顾性队列研究，纳入了印度65个中心的KE（2000 - 2024年）和7个中心的LE（2007 - 2025年）。活体供体为近亲供体，不包括利他性供体和尸体供体。研究纳入了供体和受者的人口统计学及临床数据。分析了KE/LE的原因、移植后患者和移植物存活、排斥反应及供体结局等情况。肾脏分配系统指南为：（i）在分配前完成对困难风险受者的全面移植前检查，以避免连锁反应失败。（ii）实行非匿名分配政策（与高收入国家的匿名分配不同），在此政策下，配对者在评估和手术期间可建立融洽关系。（iii）对于经验较少的移植中心，考虑进行简单的双向交换和同期手术，以避免供体反悔。
该研究共纳入1839例KE移植和259例LE移植。KE移植的分布情况为，分别来自双向、三向、四向、五向、六向和十向KE的移植例数为1594（87%）、147（8%）、44（2%）、20（1%）、24（1%）和10（0.5%）。移植配对中加入KE的原因有ABO血型不相容1610例（87%）、相容配对126例（7%）和致敏103例（6%）。存在显著的性别失衡，KE受者中男性更多，为1504例（82%），而供体中女性更多，为1469例（80%）。大多数LE为双向交换（125例双向交换对3例三向交换），主要涉及男性受者（222例男性对37例女性），原因是ABO血型不相容。
我们迄今为止规模最大的队列研究表明，交换移植在医学上简单，但在后勤方面复杂。KE或LE的可及性分布不均且可能未得到充分利用。如果能推广，我们的经验可增加移植机会，并有助于应对商业移植迫在眉睫的威胁。
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