Introduction: In a living donor kidney transplantation (LDKT) dominated transplant program, kidney exchange may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages.
Methods: Here, we report our experience of 539 single-centre kidney paired donation (KPD) transplantation to increase LDKT in India. The study has been reviewed by the ethics committee and has therefore been performed in accordance with the ethical standards laid down in the Declaration of Helsinki as well as the Declaration of Istanbul. 
Results: Between January 2000 and March 2024, 5360 LDKT and 1382 DDKT were performed at our transplantation centre, 539 (10%) using KPD. The reasons for joining KPD in transplanted patients were ABO incompatibility (n = 436), sensitization (n = 43), and better HLA/age matching (n = 60). There were 202 two-way (n =404), 29 three-way (n = 87), 4 four-way (n = 16), 2 five-way (n=10), 2 six-way (n = 12) and one ten-way kidney exchange (n = 10). All donors were near relatives [wife (n=291), husband (n=70), mother (n=108), father (n=33), sister (n=18), brother (n=10), grand-parents (n=2), son (n=1) and others (n=6)]. There were 438 male, 101 female recipients, and 423 female and 116 male donors. There was overwhelming preponderance of female donors and male recipients but similar to our LDKT program. Graft, and patient survival was 91 % (n=494) and 85% (n=450) respectively. Mean ± SD serum creatinine of functioning grafts was 1.8 ±1.3 (median 1.3 range 0-6.2 mg/dl) at mean ± SD follow-up of 7.7±4.4 (median 8.2 range 0-23.8 years).The graft survival, patient survival, biopsy-proven rejection rate, and graft function was similar to other LDKT outcomes.
It is important to recognize that over the 23 years our KPD program has evolved into the large, advanced program with innovative approaches to further increase LDKT. We credit the success of our KPD program to maintaining a registry of incompatible pairs, counselling on kidney exchange, a high-volume LDKT program, expert dedicated transplant team, patient centric policy, non-anonymous allocation, exchange of best practices and a culture of continuous improvement to develop the kidney exchange in response to innovations from other successful KPD, and Government support. 
Conclusions: This study provides large-scale evidence for the expansion of single-centre LDKT via KPD when national KPD programs do not exist. We report largest single centre cohort of KPD transplants in India and Asia.