Kidney Transplant in India: S.W.O.T. Analysis

Dr. Nitin Agarwal

Chronic Kidney disease (CKD) including End Stage Renal Disease (ESRD), commonly known as Chronic Renal Failure, has become an epidemic of alarming proportions all over the world. India, too, is in the midst of this epidemic, due to the abnormally high proportion of diabetes mellitus (DM) and hypertension (HT) in the population. ESRD is irreversible and mandates renal replacement therapy (RRT), either as dialysis or renal transplant. Renal Replacement therapy can be done in three ways, Haemodialysis, Continuous Ambulatory Peritoneal dialysis and Renal Transplantation. In terms of quality of life and longevity, transplantation remains the best form of replacement. Renal transplant can be from Live (related or unrelated) or Deceased (cadaveric) donors. The latter can be donation after brain death (DBD) or cardiac death (DCD). Transplantation in India is governed by The Transplantation of Human Organs Act, 1994, along with its subsequent modifications, most recent in 2014.



  1. DEMOCRACY: India is the largest democracy in the world with a stable government and an ancient civilization. The government is accountable to the people and all laws and rules are passed after due process, without any coercion. This is important in transplant as there is a huge question of ethics involving transfer of human organs.
  2. LAW IN PLACE: Recognizing this, the government has passed a law in 1994, The Transplantation of Human Organs Act, 1994, which in 2014 was modified keeping in mind the changing requirements of society. With a law in place, both the patients and health personnel can work within a framework to provide the best for the large number of patients suffering from ESRD.
  3. NOTTO: In the last two decades, a National Organ and Tissue Transplant Organization has been set up in Delhi. NOTTO is a central body which controls all transplant activity including registering, monitoring, popularizing and promoting organ transplant. Through ROTTO’s and SOTTO’s, its’ regional and state arms, it aims to bring organ transplant facilities to the whole country in transparent and contemporary manner.
  4. QUALITY DOCTORS: The trained Indian doctors are at par with the best in the world. Indian expertise in advanced surgical procedures including transplant is well-recognized, only the numbers needed are much higher than presently available.
  5. MEDICAL TOURISM: The rise of a well-equipped system of private and corporate hospitals offering quality healthcare at a fraction of the cost as compared to the Western countries has led to a booming medical tourism industry. This caters to patients from countries deficient in such world-class care. This has the potential to increase revenues for the local health industry and facilitate growth in the transplant sector too.
  6. LARGE NUMBER OF UNTAPPED DECEASED DONORS: The casualties from road accidents in India are one of the largest in the world. Many of these are otherwise-healthy, young individuals. While the government should make all efforts to prevent and treat these victims, some of them may be identified as potential organ donors for other suffering patients. This calls for a sensitive approach involving their families and society in general. Some countries like Spain use a policy of ‘presumed consent’ wherein such individuals are presumed to have donated their bodies to the state, and their families can be approached for this purpose after they are declared brain-dead. Using this policy, Spain has one of the highest transplant rates in the world, with a negligible waiting list.
  7. STRONG FAMILY AND ‘CAREGIVERS’: Even as the numbers and proportion of deceased donors for renal transplant in India is hugely unsatisfactory, a silver lining is that the absolute numbers of live donor renal transplants in India every year (~6000) rival those in leading countries like the USA. Live related renal transplantation (LRRT, including spousal donors) is important in India in the context of the financial, emotional and physical support it provides. Family donors in India are essentially ‘caregiver donors’ because they are associated with the intimate care and treatment of the CKD patient right from the time of diagnosis and beyond. Amongst these donors, it is unsurprising and praiseworthy that women (wives, mothers and sisters) constitute almost 90% of the total. This strength of Indian women can serve as encouragement and motivation to society.
  8. NON-GOVERNMENTAL ORGANIZATIONS: These have played a sterling role in the promotion of transplant and building awareness. Their efforts over the last three decades are now showing results.


  1. LONG WAITING LIST: At a conservative estimate, almost 2,00,000 patients of ESRD need a renal transplant in India every year; of these, only about 6000 are performed, and half the remainder die waiting for a transplant. The ratio of live: deceased donors is close to 95:5, the reverse of that seen in most developed countries.
  2. LACK OF INFRASTRUCTURE, PERSONNEL: Most patients in India are poor, and are dependent on public hospitals for health needs. However, the facilities for renal transplant in public hospitals are deficient, and have not grown substantially in the past three decades. Most tertiary hospitals attached to medical colleges do not have these facilities, even in the main urban centers. Facilities of dialysis, which is a bridge therapy before renal transplant, are also abysmally lacking.
  3. LATE PRESENTATION: Poverty, poor primary care, a vast geographical area and other factors contribute to late presentation of ESRD patients to the hospital. This leads to suboptimal results of renal transplant, which is ideally performed ‘pre-emptively’.
  4. POOR AWARENESS: Social, economic, cultural, religious factors combine together to contribute to poor awareness amongst the public regarding the problem of ESRD, its treatment, benefits of transplant, and the importance of deceased organ donation. Though there are a large number of potential donors after brain death (DBD), and the law has been suitably modified for this purpose, it is a technical and emotional challenge to motivate families in this regard. The public perception of the irreversibility of brain death is unclear in many ways.
  5. POOR INTEGRATION OF HEALTH FACILITIES: In many countries, donation after cardiac death (DCD) has emerged as an important option, with rates of almost 40% of all donors in some centers. However, this is an anticipatory approach, and mandates having intensive care and advanced surgical facilities at all secondary health centers. This is because the organs harvested from such donors have a very limited window to be used successfully. After cardiac arrest, the blood supply to the kidneys stops immediately, and, unless they are retrieved within minutes, the short-term and long-term function is unsatisfactory. Hence, integration of health systems across the country has to be strong before DCD can be used successfully as a strategy. This requires long-term planning.
  6. PROHIBITIVE PRICING OF IMMUNOSUPPRESSIVE DRUGS: It is also less understood that the long-term success of the renal graft depends on the life-long use of immunosuppessive medication, which is medically safe and available. However, the minimum cost per patient per month is Rs. 10,000, which is not feasible for most and is not covered under any health scheme. This is a stumbling block in the success of the transplant program.


  1. BOOMING MEDICAL INDUSTRY: The rise of the private healthcare industry can contribute significantly provided that the costs are kept affordable using insurance and other models. Public-private partnership is the need of the hour.
  2. LARGE NUMBER OF CASES: The large numbers can be used as an opportunity to fuel research in this area. Large centers can combine their results and channelize to NOTTO.
  3. YOUNG POPULATION: The population of India is young, and will continue the same way till at least 2050. This makes them receptive to new ideas, and also helps in achieving better medical outcomes.
  4. NETWORK OF QUALITY MEDICAL COLLEGES: The large number of state-owned medical colleges developed since independence and the subsequently-developed private colleges offer a readymade solution to augment renal transplant facilities. Renal transplant needs very few high-cost specific inputs; existing operating rooms and trained personnel along with co-ordination cam achieve the desired results. NOTTO has already proposed converting smaller hospitals into purely retrieval centers.
  5. GOD-FEARING SOCIETY: Indian society has traditionally been religious and philanthropic. The sacrificing nature of the family and women in particular, has already been highlighted. This strength can be channelized into the transplant policy.


  1. EVER-INCREASING NUMBERS: The continuous population growth and the increase in the incidence of diabetes and hypertension imply that, unless our efforts are time-bound, the problem of CKD may become insurmountable. Primary health and preventive health are equally important to control this epidemic.
  2. OPTIMUM RESULTS: Renal transplant for medical professionals is a challenging and intensive field. Suboptimum results can lead to lack of motivation amongst patients and doctors. It is important that established guidelines are followed and no short-term measures are used. By law, only registered centers can undertake transplant operations. There are stringent fines and punishments for violation of the
  3. EXPLOITATION AND TOUTS: Any resource which has a poor supply: demand ratio is vulnerable to infiltration by unscrupulous elements. The public and doctors should be well aware of all the laws and rules. Human organs are not for sale; in this regard, the poor population must be protected at all costs. An example to quote is Iran, where a kind of paid donation is allowed. However, this has allowed exploitation and profiteering to flourish.
  4. QUACKERY: Many quacks and unqualified people offer one-time remedies to the desperate and suffering patients. These are dangerous as often patients land up with uncorrectable complications. Awareness again is the key in this regard.


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