Transplant International · 8 authors, 6 centres
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This retrospective study of 2,040 kidney transplants in Nepal (2008–2022) reveals stark disparities: 79% of recipients were men, 70% of donors were women, and 32.52% of recipients came from Bagmati province (20.97% of population) while only 2.80% came from Karnali. These findings highlight the need for regional healthcare restructuring, universal coverage, and a national deceased donor program to improve equitable access.
**Background** Health equity, as defined by the WHO, is the ideal state where every individual has a fair opportunity to reach their optimal health potential. Transplantation is a life-saving treatment for end-stage organ failure, improving survival and quality of life while being economically viable. In low-resource settings like Nepal, achieving equity faces challenges including lack of infrastructure, limited human resources, low healthcare expenditure, sociocultural behaviors, and a large rural population (79% rural). Nepal's population is 29.16 million (2021 census), distributed across seven provinces: Koshi (17.01%), Madhesh (20.97%), Bagmati (20.97%), Gandaki (8.46%), Lumbini (17.56%), Karnali (5.79%), and Sudurpaschim (9.24%). The country has 142 caste/ethnic groups: Brahmins (11.29%), Chhetris (16.45%), Newars (4.60%), Janajatis (36.04%), Dalits (12.38%), and Madhesis (19.24%). Healthcare is a hybrid public-private model, predominantly out-of-pocket, with per capita GDP of USD 1,037 and healthcare expenditure at 4.45% of GDP (World Bank 2022). The government provides subsidies through the Disadvantaged Citizens Medical Treatment Fund for eight chronic conditions, including renal failure. The National Health Insurance bill was endorsed in 2017 aiming for universal health coverage by 2030. Non-communicable diseases are rising, with estimated annual incidence of end-stage kidney disease at 100 per million population. Kidney transplantation began in August 2008 at the Institute of Medicine, Tribhuvan University Teaching Hospital, primarily living donor transplants. The law restricts donation to close relatives; the 2016 amendment included brain death criteria and pair exchange. The government provides around USD 5,000 per patient for kidney transplantation and one year of immunosuppressants, plus up to USD 900 per year post-transplant under national health insurance. Despite this, many patients face barriers, prompting this study to examine current status and equity in access.
**Methods** This retrospective observational study was approved by the Institutional Review Committee of the Institute of Medicine [R. no. 551 (6-11) E2]. It included all kidney transplant recipients up to December 2022 across five major hospitals. Data on gender, ethnicity, caste, place of residence, and donor relation were collected from hospital records. Data on dialysis centers, hemodialysis machines, registered nephrologists, and transplant surgeons were obtained from the Department of Health Services, dialysis units, and the Nepal Society of Nephrology. Analysis assessed distribution of gender, geography, caste, and ethnicity in transplantation access.
**Key Results** Until December 2022, 12 centers were approved for kidney transplantation, but only five were actively performing. All active centers except two (in Koshi and Lumbini) were in Bagmati. A total of 2,040 kidney transplantations were performed from August 2008 to December 2022. Of these, 2,022 (99.11%) occurred in five hospitals (three public, two private) in Bagmati. Among recipients, 79% were men; among donors, 70% were women. The predominant type was living donor (only eight deceased donor cases). Mothers and wives were the most common donors. By province, recipients were: Bagmati 32.52% (20.97% of population), Koshi 19.3% (17.07% of population), Gandaki 17.51% (8.46% of population), Lumbini 14.76% (17.56% of population), Madhesh 9.82% (20.97% of population), Sudurpaschim 3.56% (9.24% of population), and Karnali 2.80% (5.79% of population). By caste/ethnicity: Janajatis 31%, Chhetris 22.90%, Brahmins 14.77%, Newars 10.04%, Dalits 11.08%, and Madhesi 8.12% (despite being 19.3% of population). Nepal has 69 registered nephrologists (52 in Kathmandu Valley, Bagmati) and 12 licensed kidney transplant surgeons (11 in Kathmandu Valley). Hemodialysis machines per million population: Bagmati 72.81, Gandaki 21.78, Lumbini 16.98, Karnali 15.34, Koshi 11.67, Madhesh 8.65, Sudurpaschim 5.9. Annual transplantations rose steadily except during COVID-19 (2020-2021), with over 300 in 2022, but still insufficient compared to dialysis numbers.
**Clinical Implications** The study reveals profound inequities in kidney transplantation access in Nepal based on gender, geography, and caste. The concentration of specialists, dialysis centers, and transplant hospitals in Bagmati (especially Kathmandu Valley) leaves rural provinces like Karnali and Sudurpaschim severely underserved. The gender disparity—79% male recipients and 70% female donors—reflects patriarchal norms where men are prioritized as earners and women as caregivers. Caste-based disparities show Madhesi and Dalit communities underrepresented, while Brahmins, Chhetris, and Janajatis are overrepresented. These findings align with global literature on ethnic and gender disparities in transplantation. The solution requires restructuring healthcare for regional autonomy, implementing uniform universal healthcare, and promoting deceased donor programs to bridge gaps and address disparities. The recent development of a digitalized central wait-listing platform and the need for a dedicated National Organ Transplantation Office are critical steps forward.