Scale of unmet solid organ transplantation need in India: a projection for organ transplant need by 2040.

BACKGROUND: Solid organ transplantation (SOT) is the definitive therapy for end-stage organ failure. Despite the world's third-highest transplant volume, India has no systematic assessment of unmet transplant need across organs. METHODS: We modelled 1) Global Burden of Disease 2021 organ-specific disease incidence. 2) Global Observatory on Donation and Transplantation for SOT data, and 3) IHME demographic projections till 2040. Evidence based eligibility multipliers (kidney 5%, liver 2%, heart 1%, lung 0.3%), were applied for SOT need. We modelled four transplant supply scenarios (flat supply, pre-COVID-19 trend, moderate reform (8-10%/year growth), and aspirational expansion) to estimate coverage and unmet demand. FINDINGS: In 2021, estimated annual transplant need was 125,894 (95% uncertainty interval 115,983-136,156) kidney; 184,542 (169,563-198,686) liver; 83,841 (65,602-99,462) heart; and 11,253 (10,285-11,606) lung transplants. Actual supply met only 7.2% of kidney, 1.5% of liver, 0.2% of heart, and 1.2% of lung need. By 2040, need is projected to reach 143,722 kidney, 210,649 liver, 95,711 heart, and 12,846 lung transplants annually. Even under moderate reform, 2040 coverage reaches only 32.6% for kidney and remains below 7% for liver, heart, and lung. In 2024, five states accounted for 80-96% of SOT despite representing only 29% of the population. INTERPRETATION: Our report quantifies a large and persistent gap between transplant need and supply in India. Thus, this study provides a quantitative basis for national and state-level planning to expand organ donation programs. FUNDING: None.