New Delhi: India has drawn up standard operating procedures (SoPs) for organ swaps, seeking to widen access to transplants amid a severe shortage of donor organs. The framework will allow donor-recipient pairs who cannot undergo a transplant because of blood group or tissue mismatch to exchange donors with other—through a coordinated national registry, according to two government officials and a document reviewed by Mint.
The framework has been developed by the health ministry's National Organ and Tissue Transplant Organization (Notto), which coordinates organ donation and transplantation. It aims to eventually expand beyond two-family exchanges to multi-family chains, liver-for-liver exchanges and combined kidney-liver swaps, the officials said.
The protocol has been shared with states and Union Territories for immediate nationwide rollout. The implementation hinges on states' response, they said.
Organ swaps are now mostly confined to individual hospitals, with manual matching and multiple approvals. The new rules and the registry will now help in automated matching, single-window clearances, standardized testing and simultaneous surgeries.
India's active organ transplant waitlist on the Notto national registry portal has 89,839-100,000 registered patients, with kidney making a vast majority. And this waitlist captures only a fraction of the true clinical demand. Epidemiological studies estimate that India requires between 125,000 and 200,000 kidney transplants annually, against which only 14,477 procedures were performed in 2025. For liver transplants, India requires an estimated 180,000 procedures annually but conducts fewer than 4,000.
About 20% end-stage renal disease patients with willing living family donors cannot proceed with direct transplant due to blood group mismatch or immunological incompatibility, government database shows. And roughly 10% of patients listed on deceased-donor waiting lists have incompatible family donors, who could participate in exchanges.
Replicating registry benchmarks in mature economies such as the US, UK and Australia, where paired kidney donation programmes contribute 20-26% of all living-donor kidney transplants, a functioning national pool could unlock 3,000-4,000 additional living-donor kidney transplants annually from the mismatched donor pairs, per government estimates.
India is using this model to shift from isolated, hospital-level swaps to a coordinated national network approach. India recorded 20,138 organ transplants in 2025, which included 14,477 kidney procedures. Living donors accounted for most of these surgeries, while deceased donors contributed only 3,526 transplants.
India's deceased organ donation rate was 0.87 per million population in 2025, far behind countries such as Spain that recorded over 50 per million. The paucity of deceased donors strengthens the case for robust live donor norms.
Dr Anil Kumar, director, National Organ and Tissue Transplant Organization (Notto) said– “There remains a need for SoPs and coordinated implementation for swap transplantation. It is expected to pave the way for the extension of swap transplantation to liver-liver swap and kidney-liver also and will be useful to various stakeholders for implementing a national swap transplant programme in a smooth and transparent manner.”
Mint had reported in June 2024 on the government plan to streamline swap organ donation in India.
Notably, chronic kidney disease (CKD) affects about 16% of the adult population in India, placing a heavy load on tertiary healthcare infrastructure. Nearly 20% of patients seeking living-donor kidney transplants have willing donors who are incompatible due to blood group or human leukocyte antigen mismatches.
"By enabling two incompatible donor-recipient pairs to exchange donors in a scientifically matched and legally approved manner, swap transplantation will significantly increase access to kidney transplantation while ensuring optimal clinical outcomes,” said Dr Kumar of Notto.
SoP specifics
According to the document, the framework establishes a unified online registry managed by Notto to replace manual, hospital-level matching systems with an automated allocation algorithm.
The modalities outlined in the framework stated that enrolment is restricted to legally-defined near relatives, such as spouse, parents, children and siblings, under relevant section of Transplantation of Human Organs and Tissues Act, 1994.
The SoPs mandate detailed blood and genetic testing, antibody checks, and final laboratory cross-matching before surgery to confirm donor-recipient compatibility. The computer-based matching system ranks pairs using a point score that factors in tissue match quality, blood group combinations, age difference between donors and recipients, sensitivity levels, and how close the participating hospitals are located to each other.
Moreover, the surgeries must happen simultaneously across hospitals to prevent donor backing out. While donor travel is preferred, strict transport rules have been placed to ensure organ safety if kidneys are flown or shipped.
As per the protocol, hospital panels must grant single-window legal clearance within 14 days to prevent treatment delays.
To tackle the wide cost gaps for surgeries and tests between private hospitals—which conduct 80% of India's transplants—and government ones that offer subsidized or free care, the policy suggests financial support models, uniform transplant package costs, and a government fund for needy patients.
The system uses anonymous digital code IDs to keep patient details confidential.
Lauding the framework, Dr Rajesh Aggarwal, director, nephrology at Sri Balaji Action Medical Institute, Delhi, said: “The implementation of a well-defined mechanism nationally can be an effective way to ensure some much-needed consistency in this procedure and resolve the issues that prevented its widespread use until now."
To make this system work properly, Dr Aggarwal called for effective coordination, ethical guidelines and public awareness. “A national system will allow swapping transplantation to evolve beyond the limits of single hospitals and become an organized way for the patients to get a necessary operation.”