Accurately estimating unmet transplant need is essential for planning equitable transplantation services

Access to organ transplants remains profoundly unequal worldwide.¹ Despite having one of the world's largest transplant programs,² it remains unclear how well the Indian health system meets its population's needs. A recent analysis³ numerically estimates the need for solid-organ transplantation in India. The authors calculate annual transplant need as the product of GBD disease incidence, population size, and an organ-specific eligibility multiplier (θ) and project it to 2040.

The central message that India has a large unmet need and major geographic inequities in access for transplantation is important and directionally correct. Some of the estimates, including the magnitude of heart transplant need and the conclusion that liver demand in India exceeds kidney need, are unusual and warrant examination.

The paper estimates India's need for heart transplants at 60.2 pmp. Global heart transplant activity in 2024 was 10,287 across 59 countries, covering ∼75% of the world's population, or roughly 1.7 pmp,¹ implying that India alone requires several times the world's annual output. For liver, θ = 2%, derived by the authors from natural history studies of clinically diagnosed cirrhosis,⁴ was applied to a GBD envelope in which 83% of 58.4 million incident cases were metabolic dysfunction-associated steatohepatitis (MASH), which is not a transplant indication.⁵ The estimated 1–4% of incident CLD cases progressing to transplantation annually in high-income countries (HICs), as suggested by the authors, would imply 84,000–336,000 transplants annually in HICs alone, against ∼42,000 globally.¹

The issue can be traced to the conversion of broad disease incidence into transplant demand through fixed eligibility constants. Each θ was derived in a narrow, clinically defined population and applied to a broad GBD envelope without adjustment (Table 1). GBD categories compound this: heart failure is modelled as an impairment attributed to underlying causes, of which IHD is the largest contributor,¹⁰ so combining the two indicates double counting, as does combining cirrhosis with HCC. The kidney θ makes sense as a lifetime transition probability, but the text describes proportions progressing to transplant ‘annually,’ which indicates an order-of-magnitude difference.

Table 1.

Eligibility multiplier (θ), the population in which it was derived, and the population to which it was applied.

Organ	θ	Derived in	Applied to	External verification
Kidney	5%	India's transplant-to-dialysis ratio (10,000:200,000) — a supply statistic whose denominator is dialysis initiations6	All incident CKD, a denominator ∼12 times wider	ESKD incidence 232 pmp7 → ∼320,000/year, of which 30–50% medically suitable → 96,000–160,000. The estimate falls in this range fortuitously; the derivation is invalid
Liver	2%	Natural history studies of clinically diagnosed cirrhosis4; plus an unsourced claim that Milan criteria8 select 2–3% of incident HCC	GBD cirrhosis and other chronic liver diseases (83% MASH5), combined with HCC	Same 1–4% applied to the high-income share implies 84,000–336,000 transplants/year in HICs vs ∼42,000 globally1
Heart	1%	Listing rates (<2%/year) among advanced HF — NYHA III–IV or ACC/AHA stage D	Model-derived HF prevalence, all stages and types, combined with all-stage IHD	∼5% of ambulatory HF carries any marker of advanced HF9; a defensible θ would be well below 0.1%. Gives a need of 60.2 pmp vs global delivery 1.7 pmp1
Lung	0.3%	Highly selected advanced COPD and idiopathic pulmonary fibrosis	Full severity spectrum of COPD and interstitial lung disease	Not independently verifiable; same structural mismatch

Authors have multiplied ASRs by total population. ASRs are designed for comparison between populations with different age structures, not to generate counts. Population counts require age-specific rates applied to corresponding age-specific populations and summed. The consequence is visible in the 2040 projections: all organ-specific estimates rise by the same proportion (1.1415–1.1416), simply reflecting population growth. Neither changes in age structure, secular disease trends nor disease prevention enter the model. Yet the conclusions attribute the projected expansion to aging, epidemiological transition, and improved survival and prioritized prevention. All sensible, but not supported by data.

Transferability to other geographies carries the widest consequences. Multiplying an ASR by a crude population introduces bias that scales with the gap between a country's age structure and the GBD world standard, producing large overestimates in countries with the youngest populations–concentrated in sub-Saharan Africa, where capacity to respond is weakest.

We do not argue against modeled estimation, which may be the only option where registries are absent, but suggest that outputs be validated against global delivery rates, registry listing fractions, and the physical capacity of the modeled system. Future models should use clinically relevant disease stages, estimate progression to organ failure and competing mortality, separate incident eligibility from prevalent waiting-list stock, and explicitly represent uncertainty rather than absorb it into a single fixed multiplier.

The case for expanding transplantation in India is a given, and current capacity clearly falls far short of the population's need. Quantifying that gap accurately, however, requires a denominator that reflects organ failure and transplant candidacy, rather than simply the incidence of the diseases from which they may eventually arise. Correcting the record matters: figures that cannot withstand scrutiny can harm advocacy. Meshram and colleagues have exposed the size of this gap; the next step is to build the datasets that would close it.

Contributors

VJ: Conceptualisation, literature review, writing—original draft, coordination. SN, GK, AG: Writing—review & editing. All authors reviewed and approved the final version of the manuscript.

Declaration of interests

The author declares no competing interests.