Current State of Live and Deceased Donor Kidney Transplantation in India: Challenges and Opportunities

India continues to face a significant gap between organ demand and supply, primarily because of low deceased organ donation rates and limited public awareness. The deceased donor rate remains 0.77 per million population, contributing to only 15% of transplants, with only anecdotal reports of donation after circulatory death. By contrast, living donor transplants have increased to 9.4 per million population. Globally, India ranks first in living donor transplants, third in total transplants, and 68th in deceased donor transplants. A total of 682 kidney transplant centers are registered under the National Organ and Tissue Transplant Organization (NOTTO), with a predominant concentration in the private sector (87%) and only 13% in government hospitals. Gender disparities in transplantation remain striking, underpinned by long-standing socioeconomic and cultural inequities. Between 2019 and 2023, female recipients constituted only 30% of all living donor kidney transplants, although women represented 66.2% of donors. The overall proportion of female recipients rose modestly from 28% in 2019 to 36.8% in 2023. Globally, men accounted for 64% of all recipients, with India ranked 59th among 78 countries for male dominance among living donors. Infrastructural limitations persist, with nearly 80% of immunology laboratories in metropolitan areas. Access to transplant pathology, infectious disease specialists, and advanced diagnostics remains sparse in tier 2 and 3 cities. Policy reforms-including amendments to the Transplantation of Human Organs and Tissues Act, establishment of State and Regional Organ and Tissue Transplant Organizations, and centralized coordination by NOTTO-aim to enhance access and equity. The NOTTO Chintan Shivir 2024 emphasized digital registries and protocol standardization. Although innovations such as ABO blood group (ABO)-incompatible and multicenter kidney-paired donation are advancing, broader systemic reforms are essential for long-term equity and sustainability.