Introduction: There is limited data on understanding the practices and patterns of kidney exchange (KE) procedures in India. This report will help us in digging upon the potential hurdles in developing or boosting existing KE program across the nation.
Methods: We report an ethically approved, retrospective study from 48 transplant centres about the spectrum, protocols, and outcomes of donor-recipient (D-R) pairs involved potentially in KE program.
Results: Of 44,128 cumulative transplants were performed in 48 centres. Notably, only 2.2% of the overall LDKT was attributed to KE. Of 48 centres, only one center was using software for KE matching. The median waiting time for legal clearance for KE was 4(3.1-6) months in majority of the centres. The major hurdle for KE was legal barrier (n = 28), followed by fear of unequal matches (n = 20). All(100%) centres are performing non-anonymous KE. And except for two centres, all centres were performing simultaneous surgeries in KE. Number of patients dying on KPD waitlist was 12.1%. After a match, percentage of cases backing off after meeting their respective pairs was 24.1%. Patients preferring 2-way exchange in match run was 68%. Reason for broken potential match involved potential D-R are cross match positive (56%), older donor (19%), matched donor with co-morbidity (11%), cultural (7%), waiting for better HLA match (7%) and  lack of trust (2.5%). 
Conclusion: This study highlights the need for a national registry, and robust legislation to improve more participation of D-R pairs in KE program. Increasing participation of compatible pairs in the KE donor pool could dramatically benefit hyper sensitized patients.