Four months after Karnataka became the first State to frame guidelines allowing multi-pair kidney paired exchange transplants, the initiative is yet to result in a single such transplant, with only one request having reached the State Authorisation Committee so far. August 13 is observed as World Organ Donation Day.

The request, involving a multi-pair swap arrangement for patients with incompatible donors, was approved by the committee but the transplant did not materialise following a misunderstanding between the donor-recipient families.

M. Shivalingaiah, chairman of the State Authorisation Committee, who heads the State-run Institute of Nephro-Urology, told The Hindu that the guidelines were framed and notified in April to provide an avenue for patients who had willing but medically incompatible donors.

“Before the guidelines were framed, we were receiving requests from patients who had willing donors but could not proceed with transplantation because of incompatibility. The idea behind the guidelines was to provide a structured mechanism for such patients to benefit from paired exchange,” he said.

Under kidney paired exchange, a donor who is medically incompatible with their intended recipient can donate to another compatible recipient, while the second donor gives a kidney to the first recipient. A multi-pair exchange extends this arrangement to three or more donor-recipient pairs.

Dr. Shivalingaiah said the single application received by the committee was approved after scrutiny, but the arrangement could not proceed because of a misunderstanding between the families involved. This involved patients enrolled with two private hospitals in Bengaluru and one in Hubballi.

“The framework is available, but people have to understand the process and come forward. The benefit cannot reach patients unless the donor-recipient pairs are willing to cooperate and proceed together,” he said.

The State notified the guidelines on April 4, operationalising provisions under the Transplantation of Human Organs and Tissues Act (THOTA), 1994, for exchanges involving three or more donor-recipient pairs.

The guidelines were framed in response to the difficulty faced by patients with incompatible donors, including those with ABO blood group mismatch, positive crossmatch or HLA incompatibility.

The framework permits multi-pair swaps only when each donor is a near relative of the intended recipient and the medical incompatibility of each pair is documented. Compatibility across the swap group has to be established through cross-match and HLA reports from the NABL-accredited laboratories.

All donors and recipients have to enter into a single joint agreement, and every case requires prior approval of the State-Level Authorisation Committee.. The committee is also required to interview each donor and recipient, with the proceedings video-recorded..

The guidelines prohibit any commercial transaction and require the clinical, immunological, psychological and legal evaluations prescribed under the transplant law to be completed before approval.

Where multiple hospitals are involved, the institutions have to submit an inter-hospital coordination plan, while the transplant procedures are to be performed simultaneously, as far as possible, to prevent the arrangement from breaking down.

Dr. Shivalingaiah said greater awareness among potential donor-recipient pairs was necessary to make the framework work. “People should understand the opportunity available to them, come forward and make use of it,” he said.

“We had expected that the guidelines will provide an additional avenue for patients who otherwise face difficulty accessing a kidney transplant because of donor incompatibility. However, it is unfortunate that even after four months, such multi-pair swap transplants are yet to materialise in Karnataka,” he added.