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ARTICLE
Organ Donation and Transplantation in India in 2019

Abstract

Objectives: In India, organ donation and transplant activities are managed under the National Organ and Tissue Transplant Organisation, established per the mandate of the Transplantation of Human Organs and Tissues Act 1994, as stipulated by World Health Organization guidelines.
Materials and Methods: The National Organ and Tissue Transplant Organisation reached out to various hospitals and concerned authorities at national, regional, and local levels through E-mails and telephone calls to gather and to analyze 2019 data regarding the World Health Organization-Global Observatory on Donation and Transplantation questionnaire.
Results: In 2019, India had 550 transplant centers registered with state-appropriate authorities and 140 nontransplant organ retrieval centers. Most living donors were kidney donors (8613) or liver donors (1993). Of all solid-organ transplants, most were kidney transplants, followed by liver, heart, lung, and pancreas. There were few heart and pancreas transplants in 2019, with higher percentage of female donors (65.4% and 54.3%, respectively, n = 5633 and 1084). Of transplant procedures, there were more living donor transplants (84%, n = 10 600) than deceased donor transplants (16%, n = 2023). Among all organs, wait lists for kidney transplants were higher than for other organs.
Conclusions: Reporting on organ donation and transplant of 2019 from the National Organ and Tissue Transplant Organisation, India’s national registry, continued in 2020 despite the challenges of COVID-19. India has been submitting organ donation and transplant data at the national level to the Global Observatory on Donation and Transplantation consistently from 2013 to 2019 and is the only country in the World Health Organization South-East Asia Region to have done so, providing information from all states and union territories in India.


Key words : National registry, NOTTO

Introduction

India is the second most populous country in the world, the seventh largest country by land area, the third largest transplant country in terms of the absolute number of transplants done, and the most populous democracy located in the tropical region of South Asia, having immense socio-cultural interac­tions across countries in this region. India has higher demands for organ transplantation owing to its higher load of both communicable and noncom­municable diseases among its population. This in turn stems from India’s location in the epicenter of various water-borne, vector-borne, and zoo-notic diseases1,2 and the social and health inequalities among its population.3 These factors have led to a great need for organ transplant, especially for those with end-stage organ failure.

The National Organ and Tissue Transplant Organisation (NOTTO) has established a national Web portal, which includes portals for regions and states, such that a single entry facilitates viewing the state, regional, and national levels. However, states have not been using this service, and thus online data uploading by states is not complete. Hence, data are gathered through mails and offline sources. Separate registries exist for donors and recipients, as well as for individual organs, with donor registries further categorized as living and deceased donor registries. An integration of donor and recipient information and other details at the time of upgradation of the registry is being planned along with advanced options for editing. These organ donation and transplant activities are managed under an apex national-level body (NOTTO), which was established in India per the mandate of the Transplantation of Human Organs and Tissues Act (THOTA) 1994. National level organization for oversight was stipulated by World Health Organization (WHO) Guidelines on Cell, Tissue, and Organ Transplant.4 In India, NOTTO serves as the apex center for all of India’s transplant coordination and networking activities for the procurement and distribution of organs and tissues and is India’s organ and tissue donation and transplant registry.5 India has been actively attempting to increase deceased donation rates by increasing awareness levels through various information, education, and communication activities, and it has been submitting organ donation and transplant data at the national level to the Global Observatory on Donation and Transplantation (GODT) and is the only country in the WHO South-East Asia Region (SEARO) to have consistently done so from 2013 to 2019.

The information platform GODT, which was established in 2007 in response to requests made in 2004 to the World Health Assembly under resolution WHA57.18 on Human Organ and Tissue Transplantation adopted at the 57th World Health Assembly,6-8 collects global data on the practices, safety, quality, efficacy, epidemiology, and ethical issues of allogeneic transplant.5 The WHO developed this platform in collaboration with the Spanish National Transplant Organization to implement WHA 57.18 and the Global Knowledge Base on Transplantation. These implementations allowed the collection, analyses, and dissemination of information on legislative and organizational frameworks as well as annual aggregated data of donation and transplant activities of WHO member states.6 Today, it is recog­nized as the most comprehensive source of worldwide data on organ donation and transplant activities,9 an important tool for guaranteeing the transparency, equity, and monitoring of national transplant systems,8 and a facilitator of information exchange among professionals involved and ultimately bolstering international cooperation.6 For data collection in each WHO member state, an ad hoc standard questionnaire, which includes questions on organizational systems, legislation, and annual organ transplant activity estimates from each country, is annually distributed to identified health authorities and focal points contributing to the global database.6,8,9

With the total number of solid-organ transplants increasing annually, the gap in supply of organs is widening. Although many developed countries have introduced compulsory systems of registration of donation and transplant procedures, this is lacking in many other countries, with a single comprehensive system to collect donation and transplant data on a common platform not available.6

The organ donation and transplant data collected by GODT covers almost 80% of the total world population,7,9 with kidney transplants being the largest number, followed by liver, heart, lung, pancreas, and small bowel transplants. Kidney transplant is practiced in many countries, mainly from living donors.7 With regard to liver and kidney transplant, most countries have specific legislation for organ procurement and transplantation. Among countries, differences in numbers of kidney and liver transplant rates exist by their level of development, with deceased kidney transplant more common in highly developed countries and relatively higher rates of living kidney transplants observed in developing and underdeveloped countries.7 Among the 6 WHO regions of the world, the highest rates are in the American and European region and the lowest in the African region and SEARO. Differences in living and deceased donations are mainly as a result of resource availability and existing organizational structures of that region. These differences can be due to disparate social, cultural, and religious factors. In SEARO, living donors comprise almost one-third of total organs transplanted.7

The most recent submission of data by India from NOTTO to GODT was in 2019. Here, we present important aspects submitted by India to the 2019 WHO GODT questionnaire in 2020.

Materials and Methods

To gather data for the WHO GODT questionnaire, NOTTO reaches out to various hospitals and concerned authorities through E-mails and telephone calls in a specified format and in a timely manner. In India, these E-mails are to requisite authorities at regional organ and tissue transplant organizations (ROTTOs), state organ and tissue transplant organizations (SOTTOs), state-appropriate authorities (SAAs), and hospitals in the states of Punjab, Haryana, Delhi, and Uttar Pradesh. In India, NOTTO is the Delhi-National Capital Region SOTTO, which compiles GODT data for those under its authority.

The 2019, data collection started with sending the GODT questionnaire, with E-mails sent to ROTTOs, SOTTOs, and state appropriate authorities and data compiled from May 13, 2020, to July 31, 2020. Lag time between initial communication and actual receipt of data was due to the public health situation arising as a result of the COVID-19 pandemic spread in India. Challenges faced both by staff at NOTTO and staff at transplant authorities included the strict lockdown at national, state, and district levels, transport and commuting difficulties to reach offices, and quarantine and actual contraction of COVID-19 during this time. Despite these challenges, data were collected, compiled, analyzed, and vetted by the National Ministry of Health and Family Welfare before submission to GODT. For this study, we abided by Declaration of Istanbul principles and THOTA 1994,10 which allows living donations from a near relative or from a non-near relative (that is, one by affection or attachment). Near relative as defined by the act includes spouse, mother, father, grandmother, grandfather, brother, sister, son, daughter, grandson, and granddaughter. All others are included in the non-near relative category. Relationships between donors and recipients with regard to living donations follow the THOTA Act Section 9 Subsections 1 (1A, 1B, 1C) and 3 (3A), which also applies to paired exchange transplant procedures.10

Per THOTA 1994, living donors are either near related donors (mother, father, husband, wife, brother, sister, grandfather, grandmother, son, daughter, grandson, and granddaughter only) or non-near related donors from affection and attachment (uncle, aunt, cousin, mother in law, father in law, friend). For the GODT format for collection, only information on relationship for living donor kidney transplants were collected. With regard to deceased donors, allocation is done as per the wait list and allocation criteria, with unconnected relationship between donor and recipient.

Results

Transplant centers in India
Organ transplant and retrieval centers officially registered with state-appropriate authorities in the 28 states and 9 union territories in India are classified as either transplant centers or nontransplant organ retrieval centers (NTORCs). For data collection, E-mails were sent to all states and union territories, to respective SOTTOs where they existed, to state organ transplant organization where SOTTOs were yet to be established, and to state-appropriate authorities. In 2019, there were 550 transplant centers and 140 NTORCs officially registered with state-appropriate authorities. With regard to distribution among transplant centers in 2019, there were 523 kidney, 185 liver, 134 heart, 74 lung, 60 pancreas, and 19 small bowel transplant centers. As of December 31, 2019, the following number of centers were registered with the national registry in NOTTO: 404 total transplant centers (369 organ, 35 tissues) and 50 NTORCs (32 organ, 28 tissue) (Table 1). Efforts to ensure 100% registration in the national registry are being pursued through E-mails, telephone calls, letters, and other means of communication.

Waiting lists
In 2019, numbers on wait lists by organ were as follows: 29 636 kidney, 7362 liver, 975 heart, 343 lung, 121 pancreas, and 14 small bowel. In 2019, 8138 new patients were added to the kidney transplant wait list, with 569 patients who died while on the wait list and 25 430 patients still waiting for kidney transplant on December 31, 2019. On December 31, 2019, there were 38 164 patients on dialysis. Of 1178 interviews conducted asking for consent to donate, there were 457 family refusals (approximately 39%).

Organ donation and classification of organ donors
Among organ donors in India, most are living donors. Around 715 actual deceased donors were reported in 2019, with 712 utilized (99.6%). With regard to age groups of deceased donors, most belonged to the 18- to 59-year-old age group (76%; n = 544), followed by those >60 years old (18%; n = 127), with only 6% in the <18 year age group (n = 41). In 2019, all deceased donors were brain dead donors (DBD), with no donors after circulatory death (DCD) of any of the following categories: cardiac arrest (uncontrolled), cardiac arrest while brain dead, or withdrawal of life-sustaining therapy (controlled). There were 8613 living kidney donors (81.2%), 1993 living liver donors (18.8%), and 2 domino liver donors (0.02%). The male-to-female ratio in India for deceased donors in 2019 was 76:26; for living donors, it was 37:63, reflecting a disparity between males and females (Table 2).

Kidney transplant activities in India in 2019
Of 9751 kidney transplants performed in India in 2019, there were 243 pediatric transplants (<18 years old; 2.5%), 1138 deceased donor transplants (11.7%), and 8613 living donor transplants (88.3%), which went to 7017 male (72%) and 2734 female recipients (28%). Among 1138 DBDs for kidney transplant, 1123 were single kidneys and 15 were dual kidneys. Most living kidney donors per GODT criteria were related donors (98%, n = 8439), with 174 paired exchange or cross-over exchange of near related donors with ABO incom­patibilities and/or high panel reactive antibodies. No nondirected altruistic or directed altruistic donations are permitted per law (Table 3). Table 4 shows the relationships between living donors and recipients.

Liver transplant activities in India in 2019
There were 2592 liver transplants done in 2019 in India, with 23.1%, (n=599) from deceased donors and 76.8%, (n=1991) from living donors. Of total liver transplants, 123 (4.7% of all liver transplants) were pediatric transplants. There were 1927 male (74.4%) and 665 female recipients (25.7%). Of 599 total deceased donor liver transplants, 96.8% were from DBDs and 19 (3.2%) were split liver procedures. Of note, both DBDs and DCDs are allowed; however, in 2019, all deceased donors were DBDs; per GODT criteria, 3.2% of these DBD donors’ livers were split accounting for the extra transplants. Most sources of living liver donor transplants were from lobes or segments donated by 1 donor, with few from lobes or segments from 2 donors.2 There were 4 combined kidney-liver (1 lobe) transplants (Table 5).

Heart transplant activities in India in 2019
There were a total of 187 heart transplants in 2019, of which 20 were heart-lung transplant procedures (10.7%); 22 were pediatric transplants (11.8%). There were 140 male (74.9%) and 47 female recipients (25.1%) (Table 6).

Lung transplant activities in India in 2019
Of 114 total lung transplantations, 8 were pediatric transplants. There were 62 male (54.4%) and 52 female recipients (45.7%). Entire lung transplants were all from DBDs. There were 51 single lung (44.7%) and 63 dual lung (including heart-lung) transplants (55.3%) with no living donor lung transplants (Table 6).

Pancreas transplant activities in India in 2019
Of 22 pancreas transplants, none were for pediatric patients. There were 16 male (72.7%) and 6 female recipients (27.2%). All procedures involved DBDs, which included 5 pancreas alone transplants (22.7%) and 17 kidney-pancreas transplants (77.3%) (Table 6).

Small bowel transplant activities in India in 2019
In 2019, were no small bowel transplants in India.

Organ transplant recipients in India in 2019
In 2019, 12 625 recipients received organ transplants, which included 393 pediatric recipients (3.1%). There were 9138 male recipients (72.4%) and 3487 female recipients (27.6%). Of total recipients, 2023 received organs from deceased donors (16.0%), 10 600 received organs from living donors (84.0%), and 2 (0.02%) were domino livers. The 2023 transplants from deceased donors included all combinations of DBD, including more than 1 organ transplanted, with 1427 male and 596 female recipients (70.5% and 29.5%, respectively). Figure 1 shows the state-wise distribution of deceased donor transplants in India, showing maximum numbers in Tamil Nadu, Maharashtra, Telangana, Karnataka, and Gujarat,11 followed by moderate numbers in Rajasthan, Madhya Pradesh, Uttar Pradesh, and West Bengal; the lowest numbers were in the northern, and eastern, and north-eastern states. The 10 600 living donor recipients received kidney, liver, and all combinations of lobes of liver from 2 donors, as well as had more than 1 organ transplanted, which included 7709 male recipients (72.7%) and 2891 female recipients (27.3%). Figure 2 shows state-wise distribution of living donor transplants in India, which also illustrates the regional disparity in living transplants. Living organ transplants were highest in Delhi, Tamil Nadu, Maharashtra Kerala, West Bengal, and Gujarat. Moderate numbers of living transplants were shown in Rajasthan and the remaining southern-most states. The northern, eastern (except West Bengal), and north-eastern states had the lowest number of living transplants. There were 2 domino donor recipients in 2019 (both male recipients).

Discussion

The Indian national authority responsible for overseeing donation and transplant activities at the national level, NOTTO, operates on public funding and reports to the national health ministry of India, as well as oversees safety and quality at the national level; NOTTO is responsible for promotion of organ donation, setting up of protocols and guidelines, managing wait lists, coordinating organ procurement and organ allocation, and coordinating donor registries and transplant follow-up registries. The NOTTO is not affiliated with any international organ allocation organization. For approval of organ transplants, hospital-based, district-level, or state-level authorization committees are used. The director of NOTTO is responsible for managing organ donation and transplant matters at the national level.

The registries collect socio-demographic, clinical, and epidemiological data for both deceased and living donors. Although posttransplant recipient follow-up and posttransplant living donor follow-up do exist in India, there are variations with regard to level of operation (ie, national/state/hospital level and by specific organ). Both national-level (for kidney) and local- or hospital-level follow-up (for other organs) for living donors and recipients exist. However, issues with compliance in uploading data at the national level exists. There is no surveillance system in place yet for reporting adverse events in organ transplant recipients.

India does not have any systematic public educational program on donation and transplantation at the school level; however, there are training programs in the country for staff involved in organ procurement and organ transplant. The processes relating to deceased donors, such as deceased donor identification, criteria for donor selection, and screening for transmissible diseases, are based on protocols or guidelines determined at the national and at the state level. Transparent systems with specified criteria for selection of recipients and organ allocation in donation from deceased persons exist.

Criteria for selection and exclusion of recipients and the unique identification of donors and recipients
The criteria applied for ensuring fair and equitable organ allocation are clinical severity (including age), compatibility, time on wait list, and geographical criteria. Waiting lists exist for kidneys, livers, hearts, and lungs, and they are managed at the national, regional, state, and hospital level. For execution, NOTTO has regional and state organ and tissue transplant organizations. In India, exclusion criteria for organ transplant candidates include donations to foreigners by living Indian donors (unless they are a near relative as per law). Foreigners are allowed to receive organs from deceased donors only after all Indian patients and persons of Indian origin on waiting lists have been exhausted. There are also mechanisms to ensure confidentiality and protection of privacy of donors and recipients.

At the national level, mechanisms exist to ensure that each organ donor and organ recipient are uniquely identified; however, such mechanisms cannot uniquely identify each organ. Organs retrieved from a single donor are traced by a unique donor (and their recipient) identification. Systems are in place to ensure traceability.

Transplant costs and governmental support
Organ procurement expenses and transplant costs are covered either by state or by recipients personally. The recipients themselves pay for posttransplant care and medications, with the exception of below poverty line (confirmed) patients for whom there are 10 000 rupees per month available toward posttransplant immunosuppressive medications from central funding12 under the national organ transplant program and the Rashtriya Aarogya Nidhi scheme for provision of transplant surgery. Similarly, recipients also pay for living donors themselves and for any intervention derived from the transplant (including diagnostic, therapeutic, surgery, and immediate posttransplant follow-up care).

With regard to transplants performed abroad, there is no international cooperation to allow patients to be so transplanted. If any Indian citizen travels and gets transplanted abroad, then on their return, India has sufficient facilities for their follow-up.

Aspects of legislation in human organ donation and transplantation
The Transplantation of Human Organs Act (THOA) enacted on July 8, 1994, involves legislation on organ donation from deceased and living donors, allocation, organ transplant, and organ trafficking. The act has been amended in 2011 to include tissue and paired donations, to widen the circle of near related donors, to enhance punishments for removal of organs, and to introduce punishments for unauthorized tissue removal, as well as controlling authority for tackling commercial dealings in human organs and illegal dealings in human tissues.9

Hospitals, health care teams or units, and other bodies involved in transplant or donation procedures are authorized to do so by the government, and this authorization exists specifically for government or government-affiliated units, nongovernmental not-for-profit units, and nongovernmental for-profit units. Per legal requirements, all hospital centers, hospital teams, units, and bodies performing transplants are mandatorily required to register themselves and to report their activities to the government.

Death certification is a legal requirement for all deaths occurring within India. Criteria for deter­mination of death are specified in legal requirements, and determinations are made on the basis of neurological criteria (in the case of brain death) or on the basis of circulatory and respiratory criteria in case of circulatory death. Legislation of brain stem death was achieved through the THOA 1994 legislation.

Explicit consent, donor registration, and consent for organ donation
Explicit consent is required for legal deceased donations from the next of kin, in contrast to presumed consent, prevalent in certain countries. When registering for personal official document, such as an identification card or driving license, individuals can give their consent to register for deceased donation. Nevertheless, consent of next of kin is mandatory in all cases including those who have pledged for organ donation in the national registry. For those who have not registered for donation, consent of family or next of kin can enable organ donation after death. However, refusal from family or next of kin can cease donation after death. India has a registry of identified donors who have already stated their intent to be available for organ donation. The act of giving consent by families of deceased individuals is not incentivized, and it is not legally permitted in any form. Consent for organ donation is specified for each organ and/or tissue in Form 8 of the THOTA 2014 rules. Pledges from individuals that specify the preferred organ and/or tissue for donation is in Form 7 of the THOTA 2014 rules. Legally, all transplant retrieval centers, hospital teams, and units are required to report to the government the number of actual donations from deceased individuals.

Other aspects of organ donation and transplantation in India
Per guidelines in India, purely altruistic donations to an unknown recipient are not permitted. For living donations, prerequisites include psychiatric evaluations of donors and written consent of donors. Specifically, approval is granted by the competent authority for near related donors and by the authorization committee for non-near related donors and foreigners (both donors and recipients). Legally, living donors should be informed about the risks and consequences of donation. Financial incentives are not legally permitted for living organ donations, and no such incentives are provided in any way to potential living donors. There are no legal restrictions on the coverage of donation costs for living donor. Unfortunately, there is no legal requirement for provision of care to living donors by national, state, local, or hospital units in case of adverse health or medical consequences of donation. However, follow-up and outcome registries of living donors are legally required, to include information in an established registry; organ trafficking and transplant com­mercialism are prohibited, and penalties exist if the legal requirements are not followed. Removal of organs and/or tissues without authority and commercial dealing is also prohibited. There is no provision for import/export of organs/tissues for transplantation, and there is no mention of the same in any legal enactment. Exclusion criteria include living paid donors, donation by individuals less than 18 years old, donations from mentally challenged individuals, and donations through commercial transactions.

The Global Observatory on Donation and Transplantation collects data from 194 countries and also provides WHO region-wise data. India is located in the South-East Asia region. Of 166374 total organ transplants worldwide in 2019, the share in SEARO was 8% (n = 13 495). When compared with global results, organs transplanted in SEARO during 2019 were as follows: 10% of kidneys (10 430 vs 107335), 7% of livers (2708 vs 39968), 2% of hearts (218 vs 9266), 2% of lungs (114 vs 7151), and 1% of pancreas (25 vs 2508); no small-bowel transplants occurred in SEARO, but there were 146 such transplants globally (see Table 7).

In SEARO, the share of transplants by organ in 2019 were 77.3%, 20.1%, 1.6%, 0.8%, and 0.2% for kidney, liver, heart, lung, and pancreas transplants. Global results by organ were 64.5%, 24%, 5.6%, 4.3%, 1.5%, and 0.1% for kidney, liver, heart, lung, pancreas, and small bowel transplants. With regard to the share of deceased and living kidney transplants, rates were 16.3% and 83.7% in SEARO versus 61.4% and 38.6 % globally. Similarly, rates of deceased and living donor liver transplants were 25.7% and 74.2% in SEARO versus 72.5% and 25% globally. A predominance of kidney and liver transplants were shown in SEARO, similar to Indian trends compared with global figures. Living donor transplants for both kidney and liver were higher in SEARO and India compared with global rates.

Since 2008, India has been sending organ donation and transplant data to the WHO GODT. The first director took charge of NOTTO in January 2014. The same director submitted data to the GODT questionnaire in 2013 to 2019 from NOTTO. This itself is a remarkable achievement, as India is the only one among the 11 SEARO countries to have done so, from all its 28 states and 9 union territories throughout the period with no gaps. Donation and transplant data from the respective authorities of all states and at the local level from hospitals in India were collected, despite the immensely challenging circumstances of COVID-19.

Organ allocation is based on fair and equitable parameters of wait list ranking, including age, severity, compatibility, and geographical criteria. Wait lists are maintained by organ at national, regional, and state levels. Transplant expenses are mostly borne by recipients themselves, except in cases of below the poverty line patients who come under the Rashtriya Arogya Nidhi Scheme. Aspects of organ donation and transplantation legislation in India are covered by the THOA Act 1994, which was subsequently amended in 2011.10 Consent for organ donation is not valid for all organs automatically and is specified for each organ and tissue in Form 8 of the 2014 THOTA rules.13

The 2019 data showed a skewed disparity between male and female living donors, with a ratio of 37:63; this disparity has been previously shown to be greater among living donors than deceased donors.14 India ranks third globally in the total number of transplants done annually in 2019, with the first 2 places being taken by the United States and China, respectively.15 In India in 2019, the most transplanted solid organ was the kidney, followed by liver, heart, lung, pancreas, and small bowel. Most of the kidney transplants are from living donors, with those from deceased donors being DBDs. Liver transplants were also mostly from living donors, specifically from lobes or segments from single donors, with few from 2 donors and some being combined kidney-liver transplants. Deceased donations ac­counted for almost one-third of total liver transplants; these were from DBDs with a few from split livers and a few domino transplants. About one-ninth of all heart transplants were combined heart-lung transplants, with most such transplants for male recipients. Lung transplants were either single lung or double lung, with no living transplants. The ratio of living to deceased donors for all recipients in India was almost 5:1. An increase in the number of deceased donor transplants in India, particularly for kidney and liver, could lead to a decline in the skewed distribution of deceased to living transplants; an increase in the number of transplants in India could occur through promotion of organ donation and transplant through various social media platforms and government programs. Further effective counseling and promotion of organ donation at a larger scale could lead to diminution of the male resistance to becoming a living organ donor, thus also reducing the disparity of male living organ donors. Among all organs, the wait list for kidneys is always higher than for other organs.

There are a few limitations with regard to the annual report of NOTTO as submitted to GODT, including possible missing data entries from forms as submitted by states and hospitals. Living donor follow-up data and outcome data on transplantation have not been received at the national, regional, or state level in India. Data on blood group specifications are not collected.

Conclusions

India has been performing well in the arena of organ donation and transplant, particularly in terms of overall number of transplants, which is reflected by India having the third largest number of transplants among countries. Because India has the second largest population in the world, the demand for organ transplants is high.

In India, the apex national level organization NOTTO is responsible for management and coordination of procurement and distribution of organs and tissues and maintenance of a database on organ donation and transplant and other miscel­laneous activities; availability of data is achieved through its network with ROTTOs, SOTTOs, and registered hospitals. India has consistently submitted annual organ donation and transplant data to the international forum of GODT from 2013 to 2019, one of the few countries in South Asia and even Asia to do so. Despite the COVID-19 pandemic and the difficulties in collecting data, NOTTO with the help of its network of ROTTO and SOTTOs managed to collect and compile data within the time frame and submit it to GODT. In 2019, around 550 transplant centers and 140 NTORCs were officially registered with state-appropriate authorities. With regard to wait lists, there were 29 636 kidney, 7362 liver, 975 heart, 343 lung, 121 pancreas, and 14 small bowel patients on wait lists. Of the 715 deceased donors, most were utilized (712) and most happened to be in the 18- to 59-year age group (76%). All deceased donors were DBDs and none were DCDs. Living organ donations were much higher than deceased donations, with kidneys (81%) being the highest, followed by livers (19%). In India, most deceased donors were males (76%), but living donors were mostly females (63%). Pediatric patients constituted a marginal share of all transplants (only 3%). Most living donors were related donors. Liver transplants were mostly from living donors and predominantly from single lobe/segment from 1 donor.

Most transplant recipients were males (72%). Recipients received organs mostly from living donors (84%). There was a regional disparity in occurrence of transplants done with some states performing better than others.


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DOI : 10.6002/ect.2021.0105


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From the 1National Organ and Tissue Transplant Organisation and the 2Department of Surgery, Vardhman Mahavir Medical College and SJ Hospital, New Delhi, India
Acknowledgements: We acknowledge all of the regional and state organ and tissue transplant organizations and transplant centers for contributing data. The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Vasanthi Ramesh, Director, National Organ and Tissue Transplant Organisation, A-7-3, Sector 13, R.K. Puram, New Delhi 110066, India
E-mail: vasramesh59@gmail.com