Advocacy in Disparity: Challenges of Organ Donation for Renal Transplantation in India.

Despite ranking among the top 3 nations globally in transplant volume, India faces an acute kidney deficit: approximately 175,000 patients require a renal allograft each year, yet fewer than 14,000 procedures were completed in 2023, with family members donating in 9 out of every 10 cases. This overreliance on living donation perpetuates inequity and leaves exploitation unchecked. Donor scarcity, meagre outcomes registries, gender inequity in donation, and organ trafficking are internationally recognized challenges rather than uniquely Indian ones; in India they converge with unusual severity and are compounded by regulatory fragmentation across states. Cadaveric donation is impeded by inconsistent brain-stem death certification, absent donor programs across most northern and northeastern states, and incomplete adoption of the 2011 transplant law in 7 states. Bureaucratic authorization burdens stifle kidney paired exchange programs. No granular national outcomes registry exists. A pronounced gender imbalance-rooted in patriarchal household expectations-channels donation toward women while directing transplant access toward men. Organ trafficking and transplant tourism persist as a vital issue. Reforms require nationwide intensivist training, real-time registry infrastructure, simplified donor authorization, a centralized paired-exchange platform, mandatory female-donor follow-up, and rigorous anti-trafficking prosecution-implemented together rather than as a piecemeal approach to this pressing issue.