Operational guidelines for kidney swap transplantation in India: an ISOT-NOTTO Delphi consensus

Kidney transplantation remains the most effective treatment for end-stage kidney disease (ESKD), yet access remains severely constrained across India and Southeast Asia due to organ shortages and biological incompatibility. Although living donor kidney transplantation (LDKT) constitutes the majority of transplants in India, a significant proportion of willing donor-recipient pairs are unable to proceed because of ABO blood group or HLA incompatibility. Kidney swap transplantation provides a proven strategy to overcome this barrier. However, multicentric and interstate implementation in India remains fragmented, with variation in legal interpretation, documentation processes, allocation standards, and operational execution. We aimed to develop national operational guidelines through structured expert consensus to support safe, equitable, and scalable national swap transplantation programme implementation. The challenges and proposed solutions for establishing a national swap transplantation programme were deliberated on extensively by experts during the National Organ and Tissue Transplant Organization (NOTTO) Chintan Shivir 2024 (New Delhi), the NOTTO scientific session at Indian Society of Organ Transplantation (ISOT) 2025 (Jaipur), and the ISOT National Swap Transplantation Consensus Meeting 2026 (Ahmedabad).ISOT convened a national expert panel and conducted a modified Delphi process. Fifty structured statements were developed across six domains: legal framework, enrolment, allocation and matching, operational execution, patient safeguards, and innovation. Multicentric swap transplantation is legally permissible and operationally feasible in India, and the principal barriers to expansion are governance and standardisation rather than clinical capability. This consensus provides a regulator-endorsed operational framework that can be implemented within existing legal provisions, and offers a template for other living-donor-dependent health systems in South and Southeast Asia facing comparable regulatory fragmentation. Funding None.