Compared with long-term dialysis, kidney transplantation offers substantially better patient survival; however, donor scarcity and immunological barriers such as blood-group and human leukocyte antigen (HLA) incompatibility keep many candidates from ever reaching transplant. Kidney paired donation (KPD) works around this barrier by matching incompatible pairs into exchange chains, whereas ABO-incompatible (ABOi) transplantation removes the barrier directly through desensitization protocols. Little is known about how these two strategies compare economically, or whether any advantage they hold up when resource availability differs, since almost all published cost data originates from high-income settings. Our objective was to locate, critically evaluate, and pool the available economic evidence on KPD, ABOi living-donor transplantation, and maintenance dialysis in adult end-stage kidney disease (ESKD) patients, examining in particular whether conclusions differ among high-, middle-, and low-resource countries. This review followed the PRISMA 2020 framework, incorporating its equity-focused reporting extension. Literature was retrieved from three databases (PubMed/MEDLINE, Embase, and the Cochrane Library) covering economic evaluations (both full and partial) published from 2016 through 2025. Screening, data extraction, and methodological quality assessment were each carried out independently by a pair of reviewers, with appraisal tools selected to match study design: the Consensus on Health Economic Criteria (CHEC) for cost studies, the Philips checklist for decision-analytic models, and the Newcastle-Ottawa Scale (NOS) for observational cohorts. Each included study was then classified by the World Bank income tier and by the specific type of economic analysis it employed. Ten eligible studies spanning six countries were identified: the United States, Netherlands, Sweden, Norway, United Arab Emirates, and Iran, with seven originating from high-income settings and the remaining three from Iran, the sole upper-middle-income country represented; no low- or lower-middle-income data were found. Across every study, the conclusion pointed the same way: transplantation proved more economical than dialysis. KPD carried a similar cost burden to other transplant modalities and produced savings of approximately US$100,000 per transplant relative to continued dialysis; in the Netherlands, a paired exchange program raised discounted quality-adjusted life years (QALYs) from 6.42 to 9.65, with a net gain of 4.05 QALYs once altruistic donor chains were factored in. ABOi transplantation, though costlier than ABO-compatible (ABOc) transplantation, remained cost-effective against dialysis at US$59,564 per QALY gained. Iranian data showed markedly favorable cost-effectiveness at US$1,744 per QALY. The lower absolute ratios seen in Iran are best attributed to reduced local healthcare costs rather than any fundamental difference in the underlying economic argument. Across all three comparisons, KPD, ABOi transplantation, and dialysis, transplantation consistently emerged as the more cost-effective route to renal replacement therapy (RRT). KPD stood out in particular, generating cost savings, health gains, and sparing patients the added expense of desensitization. The most notable limitation of the current evidence base is its near-total absence from lower-resource countries, precisely the settings where questions of affordability carry the greatest weight.

Juvenile idiopathic arthritis is common rheumatic disease in children and adolescents, but renal involvement is uncommon. Renal involvement is mostly in the form of secondary renal amyloidosis presenting as proteinuria. Membranous nephropathy is an uncommon renal manifestation of juvenile idiopathic arthritis. Here, we report a case of HLA-B27-positive oligoarticular juvenile idiopathic arthritis presenting as subnephrotic proteinuria. The patient also had positive anti-phospholipase A2 receptor antibodies in the serum as well as in the glomeruli according to the immunohistochemistry assay. The patient achieved clinical remission with steroids and mycophenolate sodium.

OBJECTIVES:Gender disparity in access to kidney transplant is a well-established universal challenge. Prior to 2020, duration on the transplant wait list was the only criterium for deceased donor kidney transplant allocation in the state of Gujarat. In January 2020, the State Organ and Tissue Transplant Organization Gujarat was formed, which implemented a point system for deceased donor kidney transplant allocation policy based on human leukocyte antigen mismatch, panel reactive antibody, and donor-specific antibody, among other factors. In this system, adult female recipients are assigned 2 additional points. We investigated the effect of change in deceased donor kidney transplant allocation policy on disparities between male and female recipients. MATERIALS AND METHODS:This is a retrospective, single-center, observational study. The number of male and female recipients who received deceased donor kidney transplant was collected from the medical records at the nephrology department for the period January 2014 through December 2024. We analyzed trends using logistic regression with inverse variance weighting. RESULTS:Over the study period, 3814 kidney transplants were conducted, comprising 2732 from living donors and 1083 from deceased donors. We found a progressive increase in the percentage of women who were deceased donor kidney transplant recipients, from 27.57% in 2019 to 50.76% in 2024 (P < .001). This increase may be attributed to the compounding effect of point allocation to the categories of donor-specific antibody, panel reactive antibody, patient age, and gender. CONCLUSIONS:Our study provided new insights for resolution of gaps in deceased donor kidney transplantation between male and female recipients. Implementation of a point-based system for deceased donor kidney transplant allocation policy with extra points for recipients who are women may increase the number of kidney transplants for these recipients. A similar policy may be undertaken by other centers to achieve a temporary solution until underlying factors leading to gender disparity are better understood and methods to overcome these challenges are formed.

Organ shortage remains a critical challenge in India's transplant landscape, despite established deceased donor organ transplantation (DDOT) programmes. Many potentially viable organs from brain-dead deceased donors (DBDs) are discarded due to uncertainties surrounding donor suitability in specific clinical scenarios. To address this gap, the Indian Society of Organ Transplantation (ISOT) convened a panel of national experts to develop a Delphi consensus statement aimed at guiding transplant professionals on the feasibility of organ donation from DBDs, particularly in complex or marginal donor situations. This position statement presents 19 consensus recommendations based on real-world clinical contexts such as extremes of age, acute kidney injury, infections (including HCV, HBV, HIV, tuberculosis, and tropical diseases), malignancy, diabetes, hypertension, and various surgical anomalies. The guidance is grounded in available literature, registry data, and extensive clinical experience, with the aim of expanding the DBD donor pool across Asia and improving access to transplantation for patients with end-stage organ failure. The consensus does not function as a formal clinical guideline but rather as a practical reference tool, acknowledging the limitations in India-specific data and the contextual differences from Western transplant settings. It encourages critical care and transplant teams to perform structured assessments of organ viability, apply ethical principles, and pursue informed consent in line with local regulations.

Delayed graft function (DGF) is a frequent complication of deceased donor kidney transplantation (DDKT). It is linked to unfavorable short- and long-term graft outcomes along with longer hospital stay, increased risk of acute rejection, and more invasive procedures. In India, the factors contributing to DGF include variations in donor quality, extended ischemia times, and limited availability of advanced organ preservation techniques. These guidelines offer a detailed, context-specific strategy for the prevention, diagnosis, and management of DGF. A new risk stratification model is introduced, incorporating factors related to the donor, recipient, surgical procedure, immunology, preservation technique, and the healthcare system. This leads to the development of a scoring system that facilitates the early identification of high-risk transplants and allows for targeted preventive measures, such as donor and recipient optimization, machine perfusion, and perioperative care. For diagnosing DGF, relying solely on the need for dialysis is inadequate. We propose NOTTO-ISOT DGF criteria, staging system, and stage-wise management recommendations. General recommendations stress the importance of multidisciplinary and individualized approach with immunosuppression optimization, volume optimization, avoiding nephrotoxins, using bedside point-of-care ultrasonography-based approaches, and ongoing reassessment. Policy recommendations advocate for enhanced logistics, investment in machine perfusion technology, and maintaining a national DGF registry. These guidelines aim to enhance the standardization of care and improve the graft outcomes in DDKT.

Abstract Background and Aims Overcoming gender disparity in access to kidney transplantation is a well-established universal challenge. The SRTR data showed a greater proportion of males than females for kidney transplant waitlists (61% vs 39%). Similarly, of 831 deceased donor kidney transplants (DDKT) conducted between 1997 and 2018 at IKDRC-ITS, 68% have been male and 32% female recipients while majority of donors in living donor kidney transplants (LDKT) were females. Prior to 2020, there duration on transplantation waitlist was the only criteria for deceased donor kidney allocation. In January 2020, SOTTO Gujarat was formed which implements a point system based deceased donor allocation policy including HLA mismatch, Panel Reactive Antibody, Donor Specific Antibody, age and duration on dialysis, amongst others. 2 additional points are allocated to female recipients in this allocation system. The aim is to study the impact of change in DDKT allocation policy on gender disparity. Method This is a retrospective, single-center, observational study. Number of male and female kidney transplant recipients was collected from the medical records held by the department of nephrology between January 2014 to December 2023. The data was categorized as before and after implementation of SOTTO Gujarat guidelines and analyzed. Results A total of 3182 kidney transplants were conducted at our centre over the study period, 2231 were LDKT while only 951 were DDKT. We found the percentage of female LDKT recipients to have remained disproportionately low as compared to male DDKT throughout the study period, while there was a gradually progressive increase in the percentage of female DDKT recipients with almost a doubling of female DDKT recipients from 27.57% in 2019 to 54.19% in 2023. This may be attributed to the compounding effect of allocating points to DSA, PRA, age of patient and gender as female patients tend to have higher PRA and DSA level after sensitization. Conclusion This study provides new insights into steps that can be taken to bridge the gender gap in DDKT. It shows that implementing a point based system for DDKT allocation policy with extra points for female recipients may increase the number of kidney transplants in them. Similar policy may be undertaken by other transplant centers as a bridge to achieve temporary solution till underlying factors leading to gender disparity are better understood and ways to overcome them are formed. Action should be taken to provide for equitable access to females at all stages, from diagnosis to treatment such as intensive and timely counselling. Policies for social empowerment of women must be formed including literacy, better maternal and child healthcare and financial independence. Raising awareness and education at a grassroot level must remain the key component to change public attitude regarding organ donation and ensure equitable access to transplantation for all.

In a living donor kidney transplantation (LDKT) dominated transplant program, kidney exchange may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages.

AIM:In India, 85% of organ donations are from living donors and 15% are from deceased donors. One-third of living donors were rejected because of ABO or HLA incompatibility. Kidney exchange transplantation (KET) is a cost-effective and legal strategy to increase living donor kidney transplantation (LDKT) by 25%-35%. METHODS:We report our experience with 539 KET cases and the evolution of a single-centre program to increase the use of LDKT. RESULTS:Between January 2000 and 13 March, 2024, 1382 deceased donor kidney transplantations and 5346 LDKT were performed at our centre, including 10% (n = 539) from KET. Of the 539 KET, 80.9% (n = 436) were ABO incompatible pairs, 11.1% (n = 60) were compatible pairs, and 8% (n = 43) were sensitized pairs. There were 75% 2-way (n = 2 × 202 = 404), 16.2% 3-way (n = 3 × 29 = 87), 3% 4-way (n = 4 × 4 = 16), 1.8% 5-way (n = 5 × 2 = 10), 2.2% 6-way (n = 6 × 2 = 12), and 1.8% 10-way KET (n = 10 × 1 = 10). Of the recipients 81.2% (n = 438) were male and 18.8% (n = 101) were female, while of the donors, 78.5% (n = 423) were female and 21.5% (n = 116) were male. All donors were near relatives; wives (54%, n = 291) and mothers (20%, n = 108) were the most common donors. At a median follow-up of 8.2 years, patient survival, death censored graft survival, acute rejection, and median serum creatinine levels of functioning grafts were 81.63% (n = 440), 91% (n = 494), 9.8% (n = 53) and 1.3 mg/dL respectively. We credited the success to maintaining a registry of incompatible pairs, high-volume LDKT programs, non-anonymous allocation and teamwork. CONCLUSION:This is the largest single-centre KET program in Asia. We report the challenges and solutions to replicate our success in other KET programs.

Overcoming gender disparity in access to kidney transplantation is a well-established universal challenge. The SRTR data showed a greater proportion of males than females for kidney transplant waitlists (61% vs 39%). Similarly, of 831 deceased donor kidney transplants (DDKT) conducted between 1997 and 2018 at IKDRC-ITS, 68% have been male and 32% female recipients while majority of donors in living donor kidney transplants (LDKT) were females.