A decade of progress in kidney exchange in India

 This morning I zoomed in to the tail end of a quiet celebration in India of a decade of collaboration between the Alliance for Paired Kidney Donation  (APKD) and our Indian medical colleagues..

Mike Rees and I both had sent messages of support, and during the call I spoke about my hope that India, which already does the third most kidney transplants in the world, will in the coming decade come to be the country that does the most kidney exchange transplants. That in turn could lead to India eventually becoming a global attractor for patient-donor pairs from countries that don't have lots of transplants or exchanges, to come to India to participate in kidney exchange there.

There remain many obstacles to be overcome before that can happen, but there's been so much progress in India already that those are real possibilities.

Here's the message I emailed to the founding team yesterday:

"Dear Vivek, Pranjal, Mike, Atul  and Colleagues: It’s amazing that the collaboration  between the Institute of Kidney Diseases and Research Center at the Dr. H L Trivedi Institute of Transplantation Sciences, and the Alliance for Paired Donation is entering its second decade.  It’s been thrilling for me to observe the progress that you have made.  I recall vividly meeting Dr. Trivedi in 2019 in his hospital room, and I was later deeply honored to deliver The Dr H.L. Trivedi Oration at the ISOT Meeting  in 2022.  I’ve learned so much from Vivek, and I will never forget watching Pranjal perform a robotic surgery.  And it was memorable that you both were able to visit us at Stanford for the kidney summit organized by APKD and Stanford Impact Labs.
 

"Seeing what you have accomplished has been one of the highlights of my career in market design. It’s good that we’re all still young, since I’m looking forward to the next decade of accomplishment in India." 
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Here's Mike's message:

"Mike Rees on the 10-year anniversary of IKDRC and APKD working together

"I remember the first time I met Vivek in 2016 at the TTS meeting in Hong Kong. Vivek received the “International Transplantation Science Mentee-Mentor” Award at the TTS 2016 Congress in Hong Kong. The award recognized his work on "Impact of Single Center Kidney Paired Donation Transplantation to Increase Donor Pool in India," completed under the mentorship of Prof. H.L. Trivedi and Prof. P.R. Shah. I remember meeting Vivek, Dr. PR Shah and Pranjal at the award ceremony and thinking about how wonderful it would be if we could work together. I imagined harnessing their great passion of helping patients through kidney transplantation and paired exchange and combining that with the APKD’s powerful software employing Al Roth’s Nobel Prize winning algorithm. While in Hong Kong, Vivek and I went to dinner at my first vegetarian restaurant and there we agreed to work together to try to help expand kidney exchange in India. 
 

"Three years later I travelled to Ahmedabad in May of 2019 with Alvin Roth for the ISOT Mid-term meeting. During that trip, Al and I watched Pranjal do a retroperitoneal donor nephrectomy and a robotic kidney transplantation. It was my first time seeing a robotic kidney transplant and it was so amazing. I met Dr. Himanshu Patel on that trip and I also had the honor of visiting Dr. HL Trivedi and his wife with Vivek. What a legacy Dr. Trivedi has left and I am so proud that APKD has been able to work together with Vivek, Himanshu, Pranjal and all the members of the IKDRC team to extend his wonderful vision.
 

"Since that meeting in Hong Kong, I have now made 12 trips to India and have become a big fan of Indian food and diversity of Indian culture. I have been so impressed with the passion and commitment of doctors across India, but none more so than at IKDRC. Along the way I have been fortunate to have been joined by Atul Agnihotri, Shridhar Hanchinal, and Trilly Mathew to expand our work in India. We are so grateful for the amazing example the IKDRC team has demonstrated in terms of what is possible when hard work and technology come together to saves the lives of patients with kidney disease. It is truly a joy to celebrate today with you our tenth anniversary of the work between IKDRC and APKD as we commemorate all that we have accomplished together!"

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 Over the last decade I've blogged many times in connection with transplant progress in India.  Here's a selection related to this ten-year anniversary:

Wednesday, January 13, 2016  77 Kidney Exchange transplants in 2015 at one transplant center in India

Friday, April 14, 2017  A transplant center in India has done 300 kidney exchange transplants

Wednesday, May 3, 2017 Mike Rees in India to help remove obstacles to kidney exchange

Tuesday, May 21, 2019 Robot-assisted kidney transplantation in Ahmedabad, India.

 

Wednesday, February 3, 2021 Non-Simultaneous Kidney Exchange Cycles in India: new design, in Transplant International by Kute and Rees et al.

Thursday, October 13, 2022 The Dr H.L. Trivedi Oration at the Indian Society of Transplantation (ISOT) Meeting 2022

Tuesday, February 27, 2024  Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Saturday, April 19, 2025 One Nation One Swap: National kidney exchange in India

 Thursday, August 7, 2025 Stanford conference on extending kidney exchange

 

Fast and slow dissemination of new ideas in medicine and economics (one timeline:)

There are many differences between medicine and economics, but one of the most striking is the speed of publication. 

I publish papers in both fields, so I get to experience very different speeds, of publication and response. Publishing (and therefore also responding--both positively and negatively ) is much slower in economics than in medicine.  I've been noticing this because of recent attention to a paper I coauthored that was published in November, 2025, in the journal Transplantation. (It had been submitted in January, was revised and accepted in March, and was published online in May.)  In December the journal created and distributed to its subscriber list a narrated video abstract of the paper. You can find the video here https://vimeo.com/1146995735/486989e95c?fl=pl&fe=sh

 Our paper suggested ways that information revealed during deceased organ allocation could be used to evaluate organ quality, and expedite (i.e. speed up) the allocation process for organs at risk of being unused.  And the first published response, just three month later, suggests how such information could be used in India.

Early Refusal Pattern Phenotyping as a Surrogate for Organ Quality Assessment in Kidney Allocation
Kashiv, Pranjal MD, DM1,2; Pasari, Amit MD, DM2,3; Balwani, Manish MD, DM2,3; Kute, Vivek MD, DM4
Transplantation ():10.1097/TP.0000000000005664, February 09, 2026. | DOI: 10.1097/TP.0000000000005664

"We read with interest the recent article by Guan et al,1 which provides a comprehensive and methodologically thoughtful assessment of refusal behavior in deceased donor kidney allocation. Their distinction between single-patient and multiple-patient simultaneous refusals, derived through timestamp-based clustering, offers a methodologically robust framework that elevates routine offer-response data into a meaningful surrogate for real-time assessment of organ suitability. This approach is particularly valuable in allocation environments where decisions must be made under substantial time pressure and with incomplete ancillary information.

...

" Their observations offer global relevance and hold potential for strengthening allocation efficiency in India’s evolving deceased donor landscape." 

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Earlier:

Here's the blog post that accompanied the publication online... 

Friday, May 23, 2025  Deceased organ allocation: deciding early when to move fast

Ethical considerations and global cooperaton in transplantation, Wednesday in Cairo

It's Wednesday morning in Cairo, and here's today's conference schedule, which will include discussion of (and voting on) global cooperation in transplantation. (See my earlier post for context.) 

 

8:00 AM 08:30 AM	Opening Session of Ethical Consensus Global Consensus on Emerging Ethical Frontiers in Transplantation: Innovations & Global Collaboration	HALL A
Strategic Co-Leaders (Alphabetical)	Alvin E. Roth (Stanford University, USA) John Fung (University of Chicago, USA) Mark Ghobrial (Methodist Hospital, Houston, USA) Osama A Gaber (Methodist Hospital, Houston, USA) Sandy Feng (UCSF, USA) Valeria Mas (University of Maryland, USA)
Chairs (Alphabetical)	Ahmed Elsabbagh (University of Pittsburgh, USA) Medhat Askar (Baylor University, USA) Mohamed Ghaly (Hamad Bin Khalifa University, Qatar) Mohamed Hussein (National Guard Hospital, KSA)
Scientific Committee (Alphabetical)	Abdul Rahman Hakeem (King’s College Hospital, UK) Dieter Broering (KFSHRC, KSA) Hermien Hartog (Groningen, the Netherlands) Hosam Hamed (Mansoura University, Egypt) Manuel Rodriguez (Universidad Nacional Autónoma de México, Mexico) Matthew Liao (Center for Bioethics, New York University, USA) Nadey Hakim (King’s College, Dubai, UAE) Stefan Tullius (Harvard Medical School, USA) Varia Kirchner (Stanford University, USA) Wojciech Polak (Erasmus Medical Center, Rotterdam, the Netherlands)
Leadership of Jury Committee (Alphabetical)	Chair: John Fung (University of Chicago, USA) Vice-Chairs Hatem Amer (Mayo Clinic, Rochester, USA) Lloyd Ratner (Columbia University, USA) Maye Hassaballa (Cairo University, Egypt)
08:30 AM 09:30 AM	State of Art Lecture (1, 2)	HALL A
Chairpersons (Alphabetical)	Mahmoud El-Meteini (Ain Shams University, Egypt) Mehmet Haberal (Baskent University, Turkey) Sandy Feng (UCSF, USA)
08:30 AM 09:00 AM	From Dr. Starzl to the Future: The Evolution of Transplantation and the Call to Continue the Journey John Fung (University of Chicago, USA)
09:00 AM 09:30 AM	Organ Transplant Ethics: How Technoscientific Developments Challenge Us to Reaffirm the Status of the Human Body so as to Navigate Innovation in a Responsible Manner Hub A.E. Zwart (Erasmus University Rotterdam, Netherlands)
09:30 AM 11:00 AM	Working Group 1:	HALL A
Chairpersons (Alphabetical)	Ali Alobaidli (Chairman of UAE National transplant committee) Hermien Hartog (Groningen, The Netherlands) Khalid Amer (Military Medical Academy, Egypt) Lloyd Ratner (Columbia University, NY, USA) Thomas Müller (University Hospital Zurich, Switzerland)
09:30 AM 09:50 AM	Keynote Lecture: Xenotransplantation: Scientific Milestones, Clinical Trials, Risks, and Opportunities Jay Fishman (MGH, USA)
09:50 AM 11:00 AM	WG1 Presentation & Panel Voting Matthew Liao (Center for Bioethics, New York University, USA) Hosam Hamed (Mansoura University, Egypt) Daniel fogal (New York University, USA)
11:00 AM 11:30 AM	Coffee Break
11:30 AM 01:00 PM	Working Group 2:	HALL A
Chairpersons (Alphabetical)	Daniel Maluf (University of Maryland, USA) Karim Soliman (University of Pittsburgh, USA) Marleen Eijkholt (Leiden University Medical Centre, Netherlands) Refaat Kamel (Ain Shams University, Egypt) Varia Krichner (Stanford University, USA)
11:30 AM 11:50 AM	Keynote Lecture: Smart Transplant: How AI & Machine Learning Are Shaping the Future Dorry Segev (NYU Langone, USA)
11:50 AM 01:00 PM	WG2 Presentation & Panel Voting Hub A.E. Zwart (Erasmus University Rotterdam, Netherlands) Varia Krichner (Stanford University, USA) Eman Elsabbagh (Duke University, USA) Mohammad Alexanderani (University of Pittsburgh, USA)
01:00 PM 02:30 PM	Working Group 3:	HALL A
Chairpersons (Alphabetical)	Ahmed Marwan (Mansoura University, Egypt) Ashraf S Abou El Ela (Michigan, USA) Mostafa El Shazly (Cairo University, Egypt) Peter Abt (UPenn, USA) Philipp Dutkowski (University Hospital Basel, Switzerland)
01:00 PM 01:20 PM	Keynote Lecture: Ischemia-Free Transplantation: A New Paradigm in Organ Preservation and Transplant Medicine Zhiyong Guo (The First Affiliated Hospital of Sun Yat-sen University, China)
01:20 PM 02:30 PM	WG3 Presentation & Panel Voting Jeffrey Pannekoek (Center for Bioethics, Cleveland Clinic, USA) Abdul Rahman Hakeem (King’s College Hospital, UK) Georgina Morley (Center for Bioethics, Cleveland Clinic, USA)
02:30 PM 03:30 PM	Lunch Symposium	HALL B
03:30 PM 05:00 PM	Working Group 4:	HALL A
Chairpersons (Alphabetical)	David Thomson (Cape Town University, South Africa) Lucrezia Furian (University Hospital of Padova, Italy) May Hassaballa (Cairo University, Egypt) Abidemi Omonisi (Ekiti State University, Nigeri) Vivek Kute (IKDRC-ITS, Ahmedabad, India)
03:30 PM 03:50 PM	Keynote Lecture: Framing the Conversation: Ethical considerations at the foundation for global transplant collaboration Marleen Eijkholt (Leiden University Medical Centre, Netherlands)
03:50 PM 05:00 PM	WG4 Presentation & Panel Voting Alvin Roth (Stanford University, USA) Marleen Eijkholt (Leiden University Medical Centre, Netherlands) Michael Rees (University of Toledo, USA) Ahmed Elsabbagh (University of Pittsburgh, USA) Nikolas Stratopoulos (Leiden University Medical Centre, Netherlands)
05:00 PM 05:30 PM	Closing Session of Ethical Consensus Global Consensus on Emerging Ethical Frontiers in Transplantation: Innovations & Global Collaboration	HALL A
Strategic Co-Leaders (Alphabetical)	Alvin E. Roth (Stanford University, USA) John Fung (University of Chicago, USA) Mark Ghobrial (Methodist Hospital, Houston, USA) Osama A Gaber (Methodist Hospital, Houston, USA) Sandy Feng (UCSF, USA) Valeria Mas (University of Maryland, USA)
Chairs (Alphabetical)	Ahmed Elsabbagh (University of Pittsburgh, USA) Medhat Askar (Baylor University, USA) Mohamed Ghaly (Hamad Bin Khalifa University, Qatar)
05:10 PM 05:30 PM	State of Art Lecture (3): Reflections from a Transplant Pioneer: Ethics, Policy, and the Future of Global Collaboration Ignazio R. Marino (Thomas Jefferson University, Italy/USA)

 

Are transplants too scarce, or not scarce enough? A surprising debate about India

 India, now the most populous country in the world, does the third highest number of kidney transplants in the world (although their rate of transplantation per million population is quite low).  So transplants are nevertheless very scarce in India compared to the need, which is the situation worldwide.

Earlier this year, however, a paper by three veteran (non-Indian) transplant professionals who have headed large organizations expressed repugnance for the volume of transplants in India, and the fact that it depends mostly on living donor transplantation (LDT), suggesting it can be viewed as "both alarming and reprehensible."  Their paper's title makes it clear how they view it. 

Domínguez-Gil, Beatriz, Francis L. Delmonico, and Jeremy R. Chapman. "Organ transplantation in India: NOT for the common good." Transplantation 109, no. 2, February, 2025: 240-242. 

"The field of organ transplantation has evolved very differently across the world under the influence of different national healthcare financing systems. Healthcare is, in most countries, financed by taxation and thus through governmental budgets, in combination with private funds, mostly through contributory health insurance systems (eg, Australia, Canada, Europe, New Zealand, South America, and the United States). But across much of Asia, tertiary healthcare services, such as transplantation, are almost entirely dependent on the private finances of individuals. The impressive growth in Indian organ transplantation has been accomplished in for-profit hospitals, which have expanded Indian transplantation into 807 facilities, mostly associated with the major corporate hospital chains.6 Organ transplantation, in a part of the world where one-fifth of all people live, is thus largely not for the common good, but a treatment available for those with ample monetary resources." 

########## 

 This was followed by a firm rebuttal by distinguished Indian transplant professionals.  Their title makes their view equally clear:

Rela, Mohamed, Ashwin Rammohan, Vivek Kute, Manish R. Balwani, and Arpita Ray Chaudhury. "Organ Transplantation in India: INDEED, for the Common Good!." Transplantation 109, no. 6 (2025): e340-e342. 

 "We were deeply concerned by the article “Organ Transplantation in India: NOT for the Common Good” by Domínguez-Gil et al,  which we felt provided an unfairly critical view of the current state of organ transplantation in India. We aim to provide a point-by-point rebuttal based on actual figures and ground-reality rather than tabloid-press articles as cited by the authors.
 

"It is true that in the past 5 y, there has been an extraordinary growth in the number of transplantations in India (more than those achieved over several decades by European countries). While it is natural to be wary of this astronomical increase in transplant numbers, the authors’ assumption that this growth is likely nefarious reflects an outdated western mindset, rather than a true understanding of over 2 decades of massively coordinated effort by the Government of India, transplant professionals and all other stakeholders in the country. 

...

" The development of LDT has been presented with a negative connotation. This shows a scant understanding of the geo-socio-political idiosyncrasies prevalent in the Asian region, and unlike the west, its conventional dependence on LDT.

 ...

"The authors have further confused LDT and deceased donor transplantation with regards to foreigners having access to organs in India. The authors’ accusation of deceased donor organs being preferentially allocated to foreigner is presumptuous at best. The current organ allocation system under the aegis of the Government of India and state-wise organ transplant governing bodies is a very transparent process—and is reserved for Indian nationals.

...

" Transplant tourism being equated with organ commerce is erroneous, the authors’ fail to understand that many poor countries find India a more financially viable destination to get a transplant than countries in the west. Even affordable Governments in the middle east are moving to the east for transplantation, where the ministries have a direct tie-up with transplant units. 

"While it should be conceded that transplantation in India may not be available to all, true social upliftment necessitates broader initiatives beyond just immediate transplant availability: that of addressing poverty. Nonetheless, access to transplants for the underprivileged has greatly improved over the past decade. There are several public sector hospitals in the country that routinely provide transplantation services. In 2023, in the state of Tamil Nadu, 35.1% of all deceased donor renal transplants were performed for free in public sector hospitals (Table 1). 5 While traditionally, the private pay-from-pocket healthcare has been only for those with the resources, the central and several state governments (Tamil Nadu, Andhra Pradesh, Gujarat, etc) sponsor an all-inclusive healthcare state insurance for the poor, which includes transplantation at any approved private hospital in the state; which includes LDT.

####### 

I'm on my way to a conference in Cairo that is motivated in part by concern that healthcare in low and middle income countries has been impeded by some of the international healthcare organizations' lack of understanding or empathy for their situations. 

International Transplant Week in Egypt, 2025

 I'm preparing to spend next week in Cairo at the Donate Life Egypt 2025 International Transplant Week, where I'll give a talk on Thursday.  But much of my preparation is for Wednesday, when something potentially much more exciting is scheduled.

 

 

Wednesday (Nov. 12) will be devoted to an attempt to reach a new Global Consensus on Emerging Ethical Frontiers in Transplantation: Innovations & Global Collaboration

I'll be involved in Working Group 4: Ethical Frameworks for Regulated International Collaboration
 

Co-Chairs

    Prof. Alvin Roth — Stanford University, USA
    Dr. Michael Rees — University of Toledo, USA
    Prof. Marleen Eijkholt — Leiden University Medical Centre, Netherlands

Scientific Committee Liaison / Editorial Lead

    Dr. Ahmed Elsabbagh — University of Pittsburgh, USA<

Members (alphabetical)

    Dr. Ali Obaidli — Department of Health, Abu Dhabi, UAE
    Dr. David Thomson — University of Cape Town, South Africa
    Dr. Frederike Ambagtsheer — Erasmus University Rotterdam, Netherlands
    Dr. Gustavo Ferreira — University of São Paulo, Brazil
    Prof. Ignazio Marino — Thomas Jefferson University, Italy/USA
    Dr. Juan Navarro — Leiden University Medical Centre, Netherlands
    Dr. Lucrezia Furian — University of Padua, Italy
    Dr. Manuel Rodríguez — UNAM, Mexico (President of SPLIT)
    Dr. Mignon McCulloch — University of Cape Town, South Africa
    Dr. Nikolas Stratopoulos — Leiden UMC, Netherlands
    Dr. Vivek Kute — IKDRC-ITS, India
    Dr. Wendy Spearman — University of Cape Town, South Africa

It may be a long shot, but my hope is we can reach some consensus to replace the longstanding dogma that countries should be self-sufficient in transplantation.
 

Visualizing single versus multi-center kidney exchange: Dr. Vivek Kute

  Dr. Vivek Kute is the transplant nephrologist at one of the most active single-center kidney exchange programs in the world.  When he spoke on Thursday at Stanford's conference on extending kidney exchange, he used the slide below to help illustrate how India's move to multi-hospital kidney exchange (also  called kidney paired donation, KDP) would change the opportunities to find compatible living donor kidney transplants (LDKT)...

 H

 Here's a photo from his post-conference tweet:

 

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I've often blogged about Dr Kute's work.

Kidney and liver exchange in India

 Here's an update from Dr. Vivek Kute and his colleagues on kidney and liver exchange in India.

Kute, V. B., Patel, H. V., Banerjee, S., Aziz, F., Godara, S. M., Bansal, S. B., ... & Srivastava, A. (2025). Analysis of kidney and liver exchange transplantation in India (2000–2025): a multicentre, retrospective cohort study. The Lancet Regional Health-Southeast Asia, Volume 37, June 2025, 100597. 

One Nation One Swap: National kidney exchange in India

 In India, the National Organ and Tissue Transplant Organization (NOTTO) wrote this week to all the State organizations (the SOTTOs) announcing the plan to form a nationwide kidney exchange program, called the "Uniform One Nation One Swap Transplant Program."

This has been the work of many people for a long time.  Of particular importance has been and will continue to be Dr. Vivek Kute from IKDRC Ahmedabad

 Here's the story in the Hindustan Times.

 NOTTO writes to states, UTs to implement swap organ transplant

Here's the letter itself:

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Earlier post:

Tuesday, February 27, 2024  Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Practical market design makes policy recommendations (which can violate NBER publication policy)

The National Bureau of Economic Research (NBER) publishes a widely read series of working papers, before publication in refereed journals. They also distribute a list of papers that have been published in medical journals, since those journals don't allow prepublication in working papers.  For both these series the NBER has a rule against papers that make policy recommendations.

This is sometimes a problem for the field of market design, since practical market design is about finding ways to improve the operation of markets, which is a kind of policy advice. I encountered this recently with the two papers described below, published in medical journals, which apparently are too policy related: the policy being to save more lives by arranging more transplants, in this case of hearts and kidneys respectively. (Medical journals have their own conventions, but aren't opposed to advice on medical practice...)

I received the following email from the NBER, accompanied by a line of explanation for each paper.

The email began:

"I apologize for my belated response about your journal articles; while the subject matter is clearly vital, after review of the full-text, we determined that your articles make policy recommendations that are too specific for NBER’s policy on working papers (which we apply to papers in the article list)."

 It then continued by highlighting the offending sentences in each article:

1. Alyssa Power MD*, Kurt R. Sweat MA*, Alvin Roth PhD, John C. Dykes MD, Beth Kaufman MD, Michael Ma MD, Sharon Chen MD, MPH, Seth A. Hollander MD, Elizabeth Profita MD, David N Rosenthal MD, Lynsey Barkoff NP, Chiu-Yu Chen MD PhD, Ryan R. Davies MD, Christopher S. Almond MD, MPH, “Contemporary Pediatric Heart Transplant Waitlist Mortality,” Journal of the American College of Cardiology, Vol 84, no. 7, August 13, 2024: 620-632.https://www.sciencedirect.com/science/article/pii/S0735109724075624

"Policy language:  A more flexible allocation system that accurately reflects patient-specific risks and considers transplant benefit is urgently needed."

2. Vivek B. Kute, Himanshu V Patel, Subho Banerjee,Divyesh P Engineer, Ruchir B Dave, Nauka Shah, Sanshriti Chauhan ,Harishankar Meshram , Priyash Tambi  , Akash Shah, Khushboo Saxena,Manish Balwani , Vishal Parmar, Shivam Shah, Ved Prakash ,Sudeep Patel, Dev Patel, Sudeep Desai, Jamal Rizvi , Harsh Patel, Beena Parikh, Kamal Kanodia, Shruti Gandhi, Michael A Rees,  Alvin E Roth,  Pranjal Modi “Impact of single centre kidney-exchange transplantation to increase living donor pool in India: A cohort study involving non-anonymous allocation,”Nephrology, September 2024,https://onlinelibrary.wiley.com/doi/10.1111/nep.14380

"Policy language: We suggest stepwise progress to achieve multicentre, regional, State and then a National program. Ideally, there should be engagement by the National Organ & Tissue Transplant Organization and the World Health Organization. 

While we recommend simultaneous surgery for mDRPs in a single exchange, sometimes logistical aspects have necessitated non-simultaneous exchanges"

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Earlier posts:

Thursday, August 8, 2024  Pediatric Heart Transplants: rethinking the waitlist, by Power, Sweat...Almond et al.

 Wednesday, September 18, 2024 More on non-anonymous kidney exchange in India