Translate this page into:
Kidney Transplantation in India—Past, Present and Future
Corresponding author: Vijay Kher, Department of Nephrology, Epitome Kidney & Urology Institute, New Delhi, India. E-mail: kherv1968@gmail.com
-
Received: ,
Accepted: ,
How to cite this article: Kher V, Sahay M, Jha PK. Kidney Transplantation in India—Past, Present and Future. Indian J Nephrol. doi: 10.25259/IJN_540_2024
Abstract
Kidney Transplantation is universally recognized as the best treatment option for patients with kidney failure. The first successful kidney transplant in India was done on 2nd Feb 1971 at Christian Medical College (CMC) Vellore by Dr. Mohan Rao and Dr. K. V. Johny, 17 years after the first kidney transplantation between identical twins in Boston, USA. It marked the beginning of a new era in kidney care in India. This article reviews the history of transplantation, its current status and looks forward to the future while discussing the issues and progress made in India.
Keywords
Kidney transplantation
immunosuppression
Immunology
Paired exchange
Ethical issues
Introduction
Kidney transplantation is universally recognized as the best treatment option for patients with end-stage kidney disease (ESKD). The first successful kidney transplant in India was done on February 2, 1971, at Christian Medical College (CMC), Vellore, by the team led by Dr. Mohan Rao (surgeon) and Dr. K. V. Johny (nephrologist), 17 years after the first kidney transplantation between identical twins in Boston, USA. It marked the beginning of a new era in kidney care in India.1,2
Transplantation activity picked up across the country in the 1970s and 1980s [Table 1]. Given that kidney transplantation is transformative for patients with kidney failure, a condition whose burden is projected to grow over the coming decades,3 it is time to reflect upon the current status of kidney transplantation in India.
| Year | Centre | Nephrologist | Surgeon |
|---|---|---|---|
| 1971 | CMC Vellore | Dr. K V Johny | Dr. Mohan Rao |
| 1972 | AIIMS New Delhi | Dr. K K Malhotra |
Dr. Inder Dhawan Dr. B M L Kapoor |
| 1974 | PGIMER Chandigarh | Dr. K S Chugh | Dr R V S Yadav |
| 1974 | Jaslok Hospital (Mumbai) | Dr. Chacko Kuruvilla |
Dr. B.N Colabawalla Dr. F P Soonawalla |
| 1977* | Jaslok Hospital & Nanavati Hospital (Mumbai) |
Dr. Chacko Kuruvilla Dr. Bhupendra Gandhi |
Dr. B.N Colabawalla Dr. F P Soonawalla Dr. K N Dastur |
| 1979 | Lakeside Hospital (Bangalore) | Dr. Talwalkar |
Dr. Dilip Javali Dr. Ajit Huilgol (helped by Dr. Shyam Joshi, & Dr. M H Kamath from Mumbai) |
| 1980 | Mulji Bhai Urology & Nephrology Institute, Nadiad | Dr. Mohan Rajapurkar |
Dr. Mahesh Desai Dr. Virender Desai |
| 1981 | Green Hospital, Hyderabad | Dr. S Sahariah | |
| 1982 | Osmania Hospital, Hyderabad |
Dr. Gopal Krishan Dr. Girish Narayan Dr. Raja Mallaih |
Dr. Rangnath Rao Dr. B V Rama Raju |
| 1984 | Institute of kidney disease at Civil Hospital Ahmedabad | Dr. H L Trivedi | |
| 1984 | Sir Ganga Ram Hospital | Dr. D S Rana | Dr. S Sahariah |
| 1984 | Apollo Chennai Hospitals |
Dr. M K Mani Dr. K S Ramalingam |
Dr. Subramaniam |
| 1985 | Stanley Hospital, Chennai | Dr. Muthu Jairaman | Dr. Subramaniam |
| 1985 | Guest Hospital, Chennai | Dr. C M Thiagarajan |
Dr. C Ramachandra, Dr. Jai Chandran |
| 1985 | Vijaya Hospital, Chennai | Dr. Rajan Ravichandran |
Dr. P B Sivaraman Dr. Subramaniam |
| 1985 | Govt. Medical College, Calicut | Dr. Thomas Mathew | Dr. Roy Challi |
| 1986 | Madras Medical College Chennai | Prof. M A Muthusethupathi | Dr. Subramaniam |
| 1989 | SGPGIMS, Lucknow |
Dr. Vijay Kher Dr. R K Sharma Dr. Amit Gupta |
Dr. Mahendra Bhandari Dr. Anant Kumar Dr. Rajesh Ahlawat |
India has around 600 kidney transplant centers. Out of these, 75 are in the public sector and the rest in the private sector. A total of 13,642 kidney transplants were done in 2023, 11,791 from living donors and 1,851 from deceased donors; three of these were donated after cardiac death (DCD) by Dr. Anil Kumar (NOTTO). For a country of around 1.5 billion people with an ESKD burden of at least 200,000 patients every year, these numbers are tiny, indicating the huge gap between demand and supply.4
Transplantation of Human Organs Act
The Transplantation of Human Organ Act (THOA) provides a strong legal and ethical framework for organ donation and transplantation in India. The Act were promulgated in 1994 and amended in 2008 and 2011. The Transplantation of Human Organs and Tissue Rules were formulated in 2014.5 The aim of the THOA was to promote deceased donor transplantation and prevent illegal commercial transplantation. The 2011 amendment paved the way for setting up the National Organ and Tissue Transplantation Organization (NOTTO), which collects data from all states and union territories and submits them to the Global Observatory on Donation & Transplantation (GODT).6
Establishing a nationwide online organ transplant registry under NOTTO remains a work in progress. Multiple attempts at developing a national organ registry have not been successful. Even 50 years after the first transplant, it is alarming that we do not have a national database of kidney transplantation outcomes in the country.
Deceased donor transplantation
Deceased donor transplantation (DDT) received a formal sanction with the promulgation of THOA. The uptake of DDT has been variable across the country. Mohan Foundation, a nongovernmental organization led by Dr. Sunil Shroff, has played a pivotal role in promoting DDT through education, training, and coordination initiatives. NOTTO has now taken up the leadership role in increasing awareness about organ donation and regulating transplantation, along with SOTTO (state) and ROTTO (regional) organizations.6,7
Currently, the Southern states are ahead of the rest of the country in the implementation of DDT programs, with Telangana, Karnataka, and Tamil Nadu being the top of the list, followed by Gujarat, Maharashtra, Rajasthan, Chandigarh, and Kerala. It must be pointed out that even though ahead of others, these states service a tiny minority of their populations in need and are far behind most of the leading countries in DDT per million of the population. Jeevandan in Telangana was ranked first among the various organ transplantation programs in the country this year. Around 1400 donations have been made to date since the inception of the program in 2013, and more than 5000 organs have been retrieved. There were 200 donations in 2023 and 104 donations in 2024 to date. The Transplant Authority of Tamil Nadu (TRANSTAN) retrieved 678 organs from 168 donors in 2023. Among the Union Territories, Chandigarh excelled at organ donation, with 41 organ donors in 2022. However, the national organ donation rate is around 1/pmp (donors per million population), which needs to increase substantially to meet the needs of ESKD patients in the country.
There is a need for greater awareness and education about the importance of organ donation. The major barriers to DDT are the failure to transport trauma victims quickly and the lack of intensive care units (ICUs). ICU doctors are not engaged, there is public distrust, transplant coordinators are scarce and poorly paid, and hospitals do not follow the stipulation that all ICUs must identify and report brain deaths. Large-scale awareness campaigns need to be implemented in order to increase deceased organ donation. Steps should be taken to build public trust by optimally utilizing public health systems. Police personnel need to be sensitized to make the organ donation process smoother in medicolegal cases. Increasing the number of organ retrieval centers by making registration of non-transplant centers mandatory for retrieval is essential. Sensitizing the ICU doctors and staff in this regard and counseling by the transplant coordinator are also very important. Transparency, public trust, a just and equitable distribution system, and effective regulations are essential in improving deceased organ donation. “One nation, one organ” means the same laws for organ transplantation across the country, and one national waitlist for organs needs to be implemented sooner rather than later. This will also avoid varying practices in different states and regions and enhance uniformity and standardization of practice across the centers. Several practical challenges can be foreseen, that need to be sorted out.
Advances in kidney transplant surgery
Kidney transplant surgery for donors and recipients had started as an open surgical procedure. By 2000, many centers had adopted laparoscopic donor nephrectomy as a minimally invasive surgery for donors, which is now the standard practice in most transplant centers. Drs. Rajesh Ahlawat at Medanta Hospital and Pranjal Modi at the Institute of Kidney Diseases in Ahmedabad initiated robotic transplant surgery for recipients in 2014,8,9 and its popularity has increased over time.10
Immunological tests—changing scenario
In the early days of kidney transplantation, complement-dependent cytotoxicity crossmatch (CDC-XM) was the only immunological test. A few centers did low-resolution human leukocyte antigens (HLA) typing using serological methods. There were few specialized immunology laboratories. Dr. Balakrishnan from the Army Hospital used to provide support for CDC-XM in the late 1970s before moving to the University of Cincinnati, USA. Over time, centers and labs have incorporated advances in the technology of immunological evaluation.
HLA typing
Low-resolution HLA typing by serological methods is still the most commonly used method for HLA typing. High-resolution HLA typing is available in many standard national laboratories, essentially at a similar cost to low-resolution HLA typing. The latter is critical to the interpretation of donor-specific antibody (DSA) testing using the Luminex platform, and should be the norm for HLA typing of donors and recipients.11
Antibody testing in transplantation
For almost 40 years, CDC-XM, described by Drs. Terasaki and Patel in 1967, was the only test done to look for anti-donor antibodies in the recipient.12 A negative CDC-XM was considered to be a must before proceeding with kidney transplant surgery and continues to be done in the current era in most transplant centers.13
Flow cytometric crossmatch (FC-XM), a sensitive technique that enables the detection of the antibody of all immunoglobulin (IgG) isotypes, including both complement-fixing and noncomplement-fixing, started in India in 2010. The combination of FC-XM with panel reactive antibody (PRA) (Luminex) and single-antigen bead (SAB) assays is highly sensitive and specific for identifying clinically significant DSAs, making CDC-XM redundant.13 The use of SAB testing is limited to select centers and is usually employed only if FC-XM is positive or in high immunological risk and sensitized patients.
Cost-cutting attempts to find a substitute for these techniques have led to using tests like Lysate-based crossmatch on the Luminex platform. However, these have high false positive and negative rates. Given that they are neither reliable nor reproducible, there is no place for these tests in current-day practice.14
Technological advances in immunological evaluation, like FC-XM and SAB Luminex assays, have played important roles in improving outcomes in kidney transplantation. It is thus imperative that well-standardized assays are utilized for daily clinical practice.13,15,16 Cost is often mentioned as a barrier, but these tests are significantly cheaper than the prices even ten years ago and are cost-saving in the long run.
Immunosuppression
The modern era of immunosuppression started in India in the late 1980s with the introduction of cyclosporine. Early acute rejection (AR) rates came down and transplantation across the HLA barrier picked up. Initial practice limited cyclosporine use for one year, primarily due to cost considerations and the fear of long-term chronic cyclosporine toxicity. This led to High rates of acute rejections after withdrawal,17 Leading to a change in practice. Generic tacrolimus formulations were introduced in 2006 and quickly overtook cyclosporine as the calcineurin inhibitor (CNI) of choice. Currently, generic tacrolimus, mycophenolate, and steroids are the most common maintenance immunosuppressive agents. The use of mammalian target rapamycin (mTOR) inhibitors remains limited.18,19
Therapeutic drug monitoring, uncommon in the initial years, is now universally available. Normal trough level targets are 8–12 ng/mL in the first three months, 7–10 ng/mL in three to six months, and above 5 ng/mL (4–6 ng/mL) beyond six months. Steroid withdrawal protocols are uncommon.20
Induction Therapy
Rabbit anti-thymocyte globulin (ATG) (Thymoglobulin, Sanofi) at 2–3 mg/kg and Grafalon (ATG, Neovi marketed by Zydus) at 4–6 mg/kg are used in about 50% of transplants in India. IL2RA (basliliximab) use has declined to around 10–15%, with the rest not getting any induction.21–23
Desensitization is used for high-risk patients with moderate anti-HLA antibody titer and ABOi transplant using rituximab, plasmapheresis, and induction agents like thymoglobulin, Grafalon, and IL2RA (mostly in ABOi transplants).24
Clinical Outcomes
Acute rejection
Approximately 10–15% of patients experience AR in the first year. With ATG induction, the rates have reduced to less than 10%. AR is effectively managed by intravenous (IV) steroids 250–500 mg for three to five days and ATG for steroid-resistant acute cellular rejection (ACR). The incidence of antibody-mediated rejection (ABMR) in the first year has reduced significantly with the increasing use of sensitive crossmatch techniques and single-antigen-based assays.13,25
Patient and graft survival
There are not many studies documenting transplant outcomes. The current one-year patient and graft survival is estimated to be around 95% and 90–95%, respectively. The five-year patient and graft survival figures are 85–90% and 75–80%, respectively, and the ten-year patient and graft survival is 70–75% and 60–65%, respectively.1,25–27
Graft loss
Infections and cardiovascular diseases are the most common causes of death. Chronic ABMR, AR, death with functioning graft, and recurrent or de novo glomerulonephritis are common causes of graft loss.1,25,26
Infections
Infections remain the leading causes of morbidity and mortality. Bacterial infections like urinary tract infection (UTI), pneumonia, tuberculosis, fungal infections, and viral infections, including cytomegalovirus (CMV) and BK polyomavirus, are common in the posttransplant period.27–30 Apart from tuberculosis, the epidemiology, clinical presentation, and outcomes of other infections are not well-documented. The availability of sophisticated tests has reduced the overall burden of infections in the last decade.
Paired kidney exchange transplantation
Paired kidney exchange (PKE), done first in South Korea in 1991,31 is seen as an important strategy to increase access to transplantation, which can take the form of paired exchange, three-way, four-way, or multiway transplant.32 PKE is mainly practiced at a single-center level [Table 2].33–37,38 Successful multiway transplants have also been reported.38,39 The lack of a regional- or national-level registry is a barrier to scale-up. Difficulties in maintaining anonymity can lead to coercion and financial dealings. Rare instances of reneging by a donor have been reported.32 The report by Kute et al. on no reneging during 17 nonsimultaneous kidney exchanges appears reassuring in this regard.40 The THOA 2011 amendment made PKE easier. However, significant hurdles remain, such as the need for clearance from different authorization committees when participating pairs are from different states.
| Study | Study period and follow-up | Patient details | Outcome and remarks |
|---|---|---|---|
| Modi et al., 201033 | 2000–2009 |
34 pairs Reason for exchange: ABO incompatible in 12 and positive crossmatch in 5 pairs |
PS: 76.5% DCGS: 94.1% |
| Waigankar et al., 201334 |
2008–2011 12 months |
7 PKE Reason for exchange: ABO incompatibility in all |
PS: 100% DCGS: 100% |
| Kute et al., 201335 |
2000–2012 2.7 years mean |
70 PKE Reason for exchange: ABO incompatibility in 56, positive crossmatch 14 |
PS: 81% DCGS: 90.2% (five-year survival) |
| Jha et al., 201536 |
2010–2013 20 months median |
26 PKE versus 716 non-PKE All two-way PKE; reason for exchange: ABO incompatibility |
PS: 96.2% DCGS: 96.2% BPAR: 11.5% |
| Kute et al., 201739 | 2015–2016 |
77 PKE Reason for exchange: ABO incompatibility in 45, sensitization in 26, better matching in 6 |
PS: 93.5% DCGS: 98.7% LDKT increased by 25% in a year due to PKE |
| Kute et al., 201737 |
2000–2016 3 years mean |
300 PKE Reason for exchange: ABO incompatibility in 222, positive crossmatch in 59, better matching in 19 124 two-way; 14 three-way, 1 four-way, 1 six-way |
PS: 83.3% DCGS: 96% |
PS: Patient survival, DCGS: Death censored graft survival, PKE: Paired kidney exchange, LDKT: Living donor kidney transplantation
The NOTTO should facilitate regional and national PKE programs. PKE registries will help in increasing such exchanges. The need for multiple authorization committees’ clearances in case of interstate PKE should be abolished, with clearances coming from a central committee authorized by NOTTO. Utilizing O blood group donors in the pairs can increase the donor pool. Table 2 summarizes the Indian experience of PKE transplantation in the country.33–37
ABO incompatible kidney transplantation
Since the first reports over 10 years ago, transplantation across the ABO barrier has become common.41,42 Preconditioning regimens involve use of plasmapheresis (with or without IVIG) or immunoadsorption and Rituximab. In a report of 100 ABOi transplants,43 of the graft and patient outcomes were at par with those of the compatible group, barring the initial graft loss in the first two weeks due to hyperacute rejection. The non-availability of complement inhibitor eculizumab to tackle such a crisis remains an important issue. Such transplants are also fraught with a higher risk of infection.44,45 An Indian working group recommendation for ABOi transplant was published in 2019.46 Table 3 summarizes the Indian experience of ABOi kidney transplant.41,43,47–53
| Study | Study period and follow-up | Patient details and follow-up | Preconditioning | Induction | Outcome |
|---|---|---|---|---|---|
| Ravichandran et al., 201241 |
2009–12 4 weeks to 28 months |
13 ABOi |
PE + IVIG Ritux |
Bas |
PS: 100% GS: 85% ABMR: 15% |
| Jha et al., 201647 |
2011–14 ABOi: 10 months ABOc- 17 months |
20 ABOi versus 669 ABOc |
5 pts: PE with IVIG 12 pts: DFPP 3 pts: none Ritux |
ABOi: Bas ABOc: 55% Ritux, 5% ATG, 40% none |
PS: 90% DCGS: 95% BPAR: 15% ABMR: 0% |
| Jha et al., 201848 | 2011–2017 | 50 ABOi | PE/DFPP/IVIG | Bas |
PS: 94% DCGS: 88% BPAR: 22% ABMR: 8% |
| Thukral S et al., 201949 |
2014–2015 12 months |
30 ABOi |
PE Ritux |
ATG |
PS: 96.7% DCGS: 96.7% ABMR: 0% |
| Prabhakar A et al., 202150 |
2013–2019 26 months |
100 ABOi 100 ABOc |
PE Ritux |
Bas/Thymo |
PS: 93.3% DCGS: 73.5% ABMR: 15% |
| Mukherjee D et al., 202151 |
2014–2018 30 months |
30 ABOi | IA |
PS: 86.7% DCGS: 100% ABMR: 3% |
|
| Jha et al., 202243 |
2011–2020 33 months (median) |
100 ABOi |
PE + IVIG, DFPP ± IVIG, IA Ritux |
Bas: 65% Thymo: 11% Grafalon: 11% None: 13% |
PS: 93% DCGS: 94% BPAR: 17% ABMR: 3% Infection: 17% |
| Pawar N et al., 202452 |
2012–2021 29 months |
195 ABOi |
PE/IA Ritux |
Bas/Thymo/Grafalon |
PS: 86.6% DCGS: 89.3% ABMR: 15% |
| Kute et al., 202353 | 2011–2022 36 months | 1759 ABOi versus 33157 ABOc | IA/PE/IVIG Ritux | Bas/ATG/No induction |
Mortality: 9.5% Graft loss: 7.7% BPAR: 12.6% |
PE: Plasma exchange, IVIG: Intravenous immunoglobulin, DFPP: Double filtration plasmapheresis, ATG: Anti thymoglobulin, IA: Immune adsorption, PS: Patient survival, GS: Graft survival, ABMR: Antibody mediated rejection, DCGS: Death censored graft survival
Challenges and issues
Despite significant progress, the kidney transplant program in India faces many challenges.
Ethical issues
Despite the THOA—which provides legal framework for organ donation and transplantation in India being operative since 1994—illicit organ trade and unethical practices have continued. Reports of kidney rackets operating in different parts of the country appear frequently. Despite stringent laws, enforcement and monitoring remain inconsistent across regions, and the current penalties do not seem to be a deterrent. Besides being exploitative and coercive, these incidents bring a bad name to the country’s medical fraternity.54 In addition to established centers, these transplants are also done in hidden, unhygienic places, putting both recipients and donors at risk of complications. There have been calls for legalizing unrelated transplants through a regulated system from Western countries.55 We believe this would be going down a slippery slope where the solution may become worse than the disease. Moreover, it will put an end to altruistic deceased donors and living-related donor transplantation and may become a social catastrophe.
Gender disparity
The gender disparity between kidney donors and recipients in India has been highlighted in scientific literature as well as in the lay press. Over 70% of the transplant recipients are males, whereas females constitute over 70% of the donor population. In spousal transplants, over 90% of donors are females. This reflects the general social disadvantage females face in our country.56
Donor follow-up
The trepidation and dilemma of doing a donor surgery for the good of someone else in the first transplant in the world was highlighted in Dr. Murray’s Nobel Prize acceptance speech. Donor surgery has a low mortality (0.03–0.01%), but even one death is a death too many.57 Given the lack of high-quality, mass-based dialysis programs and a weak deceased donor program, there is a great deal of reliance on living donors. Quite often, donors with comorbidities (e.g., elderly and those with hypertension, prediabetes, diabetes, obesity, cardiovascular disease, marginal kidney function, and impaired mental health) come forward to donate. There is a need to develop a consensus for acceptable risk and document short- and long-term follow-up data of living donors for the safety of donor surgery for all living donors.
India as a transplant tourism hub
India is emerging as a medical tourism destination for kidney transplants, especially for low- and lower-middle-income countries. With the availability of state-of-the-art technology, skilled manpower, low-cost surgery, and comparable success rates with the Western world, India has all the right ingredients. However, it becomes essential to establish an enhanced legal and ethical framework so as not to allow unethical commercial transplants before we establish ourselves as a transplant tourism hub.
Kidney transplantation in India has made significant advancements in medical, surgical, and immunological work-up technology and practice, leading to improved clinical outcomes. However, the current transplant ecosystem faces challenges in relation to donor availability, ethical issues, and legal enforcement. Despite these challenges, leading transplant centers across the country continue to drive progress and provide hope to thousands of patients in need of life-saving kidney transplantation. One hopes the challenges will be resolved soon rather than later.
Acknowledgments
We acknowledge with thanks Dr. Anil Kumar, Director NOTTO (for transplant data), Dr. Thomas Mathew, Dr. S Sahariah, Dr. Chacko Jacob, Dr. Bhupendra Gandhi, Dr. Ashok Kriplani, Dr. Mohan Rajapurkar, Dr. Alan Almeida, Dr. N K Hase, Dr. S Sundar, Dr. Muthusethupathi, Dr. Edwin Fernando, Dr. Rajan Ravichandran, Dr. CM Thiagarajan, Dr. B Subba Rao, and Dr. Sanjay Agarwal for their help confirming their institution’s details about the transplantation during 1970 and 1980s.
Conflicts of interest
Dr. Vijay Kher: Consultancy Agreements, Torrent Pharmaceuticals, India; Novartis, India; Roche, India; Panacea, India; Sanofi Aventis, India; Intas Pharmaceuticals, India; Biocon Pharmaceuticals, India; GSK, India; RPG Life Sciences; Astra-zenaca, India, Emcure (Gennova), India. Honoraria: Novartis, India; Roche, India; Astellas, India; Torrent, India; Reddy’s, India; Intas, India; JB Pharmaceuticals, India. Scientific Advisor: Roche, India; Novartis, India; Torrent; Sanofi Aventis; Reddys, India, Biocon, India; Medtronics; Wockhardt, India. Speaker Bureau: Novartis, India; Roche, India; Panacea, India; Sanofi Aventis, India; Intas, India; Biocon, India; Pfizer; JB Pharmaceuticals; Astra-zenaca, India; Boehringer Ingelheim, India.
References
- Evolution of renal transplantation in India over the last four decades. NDT Plus. 2010;3:203-7.
- [CrossRef] [Google Scholar]
- Five decades of Indian nephrology: A personal journey. Am J Kidney Dis. 2009;54:753-63.
- [CrossRef] [PubMed] [Google Scholar]
- Global, regional, and national burden of chronic kidney disease, 1990-2017: A systematic analysis for the global burden of disease study 2017. Lancet. 2020;395:709-33.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Transplantation of human organs and tissues act-”simplified”. Indian J Trans. 2018;12:84-9.
- [Google Scholar]
- Why NOTTO? the national organ and tissue transplant organisation and why it is crucial to regulate organ donation and transplantation in India. Transplant Proc. 2020;52:2930-3.
- [CrossRef] [PubMed] [Google Scholar]
- Shroff “Deceased Organ Donation in India”. www.mohanfoundation.org. Archived from the original on 28 December 2018 [Last accessed on 3 Sep 2024].
- Robotic kidney transplantation with regional hypothermia: Evolution of a novel procedure utilizing the IDEAL guidelines (IDEAL phase 0 and 1) Eur Urol. 2014;65:1001-9.
- [CrossRef] [PubMed] [Google Scholar]
- Robotic kidney transplantation with regional hypothermia: A step-by-step description of the Vattikuti Urology Institute-Medanta technique (IDEAL phase 2a) Eur Urol. 2014;65:991-1000.
- [CrossRef] [PubMed] [Google Scholar]
- Robotic Kidney Transplantation with regional hypothermia versus open kidney transplantation for patients with end stage renal disease: An ideal stage 2B study. J Urol. 2021;205:595-602.
- [CrossRef] [PubMed] [Google Scholar]
- Role of molecular typing in live related donor renal transplantation. Med J Armed Forces India. 2002;58:201-4.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Significance of the positive crossmatch test in kidney transplantation. N Engl J Med. 1969;280:735-9.
- [CrossRef] [PubMed] [Google Scholar]
- Prospective multi-centric study to analyze pre-transplant compatibility algorithm for live-related donor kidney transplant in Indian setting: The “Delhi approach”! Transpl Immunol. 2021;69:101487.
- [CrossRef] [PubMed] [Google Scholar]
- Nonspecific positivity on the Luminex crossmatch assay for anti-human leukocyte antigen antibodies due to antibodies directed against the antibody coated beads. Indian J Nephrol. 2016;26:134-7.
- [CrossRef] [PubMed] [Google Scholar]
- Pre-transplant compatibility tests in kidney transplants: Case report on significance of epitope-based analysis in donor selection. Indian J Nephrol. 2020;30:57-8.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Pretransplant histocompatibility testing algorithmic: Laboratory and clinical approach in the Indian Context. Indian J Transpl. 2021;15:4-13.
- [Google Scholar]
- Impact of cyclosporine withdrawal on living related renal transplants: A single-center experience. Am J Kidney Dis. 2001;37:119-24.
- [CrossRef] [PubMed] [Google Scholar]
- Comparison of azathioprine with mycophenolate mofetil in a living donor kidney transplant programme. Indian J Nephrol. 2011;21:258-63.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Generic tacrolimus (Pan Graf) in renal transplantation: An experience of 155 recipients in India. Transplant Proc. 2008;40:2237-9.
- [CrossRef] [PubMed] [Google Scholar]
- Early corticosteroid withdrawal regimen in a living donor kidney transplantation program. Indian J Nephrol. 2014;24:232-8.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Efficacy of basiliximab induction in poorly matched living donor renal transplantation. Indian J Nephrol. 2013;23:409-12.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Role of induction in a haplomatch, related, low-risk, living-donor kidney transplantation with triple drug Immunosuppression: A single-center study. Indian J Nephrol. 2024;34:246-51.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Grafalon® vs. Thymoglobulin® as an induction agent in renal transplantation – A retrospective study. Indian J Nephrol. 2021;31:336-40.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Successful Renal Transplantation Across HLA Barrier: Report from India. Indian J Nephrol. 2017;27:210-4.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Renal transplant and its outcomes: Single-center experience from India. Exp Clin Transplant. 2019;17:78-82.
- [CrossRef] [PubMed] [Google Scholar]
- Allograft rejection in kidney transplantation – A retrospective study of impact on graft and patient outcome. Indian J Transplant. 2022;16:371-6.
- [Google Scholar]
- Evaluation of graft outcome in renal transplant recipients in a 10 year period ranging from 2008-2018 - A retrospective study (REVERTER) Kidney Int Rep. ;6:S324. Available from: http://doi.org/10.1016/j.ekir.2021.03.775
- [Google Scholar]
- Cytomegalovirus disease in renal transplant recipients: A single-center experience. Indian J Microbiol. 2012;52:510-5.
- [CrossRef] [PubMed] [Google Scholar]
- Fungal infection in post-renal transplant patient: Single-center experience. Indian J Pathol Microbiol. 2020;63:587-92.
- [CrossRef] [PubMed] [Google Scholar]
- Infection is the chief cause of mortality and non-death censored graft loss in the first year after renal transplantation in a resource limited population: A single centre study. Nephrology (Carlton). 2019;24:456-63.
- [CrossRef] [PubMed] [Google Scholar]
- Exchange-donor program in renal transplantation: A single-center experience. Transplant Proc. 1999;31:344-5.
- [CrossRef] [PubMed] [Google Scholar]
- Paired kidney exchange transplantation – pushing the boundaries. Transpl Int. 2020;33:975-84.
- [CrossRef] [PubMed] [Google Scholar]
- Living donor paired-kidney exchange transplantation: A single institution experience. Indian J Urol. 2010;26:511-4.
- [CrossRef] [PubMed] [Google Scholar]
- Living donor transplant options in end-stage renal disease patients with ABO incompatibility. Indian J Urol. 2013;29:114-8.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Outcome of kidney paired donation transplantation to increase donor pool and to prevent commercial transplantation: A single-center experience from a developing country. Int Urol Nephrol. 2013;45:1171-8.
- [CrossRef] [PubMed] [Google Scholar]
- Paired kidney exchange transplantation: Maximizing the donor pool. Indian J Nephrol. 2015;25:349-54.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Impact of single centre kidney paired donation transplantation to increase donor pool in India: A cohort study. Transpl Int. 2017;30:679-88.
- [CrossRef] [PubMed] [Google Scholar]
- Seventy-seven kidney paired donation transplantations at a single transplant centre in India led to an increase in living donor kidney transplantations in 2015. Clin Kidney J. 2017;10:709-14.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Six end-stage renal disease patients benefited from first non-simultaneous single center 6-way kidney exchange transplantation in India. World J Nephrol. 2016;5:531-7.
- [CrossRef] [PubMed] [Google Scholar]
- Non-simultaneous kidney exchange cycles in resource-restricted countries without non-directed donation – A prospective single-center cohort study. Transpl Int. 2021;34:669-80.
- [CrossRef] [PubMed] [Google Scholar]
- ABO incompatible kidney transplantation – A single center experience. Indian J Transs. 2012;6:103-6.
- [Google Scholar]
- Renal transplantation across ABO barrier. Indian J Nephrol. 2013;23:214-6.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- ABO-incompatible kidney transplantation in India: A single-center experience of first hundred cases. Indian J Nephrol. 2022;32:42-6.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Invasive gastric mucormycosis and cytomegalovirus infection in an ABO incompatible renal transplant recipient. Indian J Nephrol. 2015;25:373-6.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- ABO-incompatible kidney transplant outcomes: A meta-analysis. Clin J Am Soc Nephrol. 2018;13:1234-43.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- ABO-incompatible kidney transplantation: Indian working group recommendations. Indian J Transs. 2019;13:252-8.
- [CrossRef] [Google Scholar]
- ABO-incompatible renal transplantation in developing world – Crossing the immunological (and mental) barrier. Indian J Nephrol. 2016;26:113-8.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- ABO-incompatible renal transplantation: The journey so far on a road less traveled. IJJT. 2018;12(3):177-81.
- [Google Scholar]
- Comparative analysis of ABO-incompatible kidney transplantation with ABO-compatible transplantation: A single-center experience from Eastern India. Saudi J Kidney Dis Transpl. 2019;30:97-107.
- [Google Scholar]
- Kidney transplantation with ABO-incompatible donors: A comparison with matched ABO compatible Donor Transplants. Indian J Nephrol. 2021;31:358-64.
- [Google Scholar]
- Use of immunoadsorption columns in ABO-incompatible renal transplantation: A prospective study at a tertiary care center in India. Med J Armed Forces India. 2021;77:15-21.
- [Google Scholar]
- ABO-incompatible renal transplant: A single-center experience from India. Indian J Nephrol. 2024;34:24-30.
- [Google Scholar]
- A multicenter retrospective cohort study on management protocols and clinical outcomes after ABO-incompatible kidney transplantation in India. Transplantation. 2024;108:545-55.
- [Google Scholar]
- Organ transplantation in India: Not for the common good. Transplantation. 2024;2024
- [Google Scholar]
- A regulated system of incentives for living kidney donation: Clearing the way for an informed assessment. Am J Transplant. 2022;22:2509-14.
- [Google Scholar]
- Thirty-year trends in perioperative mortality risk for living kidney donors. JAMA 2024:e2414527.
- [Google Scholar]
