Medical breakthrough: How a 4-way kidney transplant connected families from Kashmir to Nagaland

In a major medical breakthrough doctors have successfully executed a rare four-way paired kidney swap transplant. The intricate chain brought together eight individuals, four patients suffering from end-stage renal disease and their respective willing living donors from diverse geographic backgrounds across Jammu & Kashmir, Delhi, Bihar, and Nagaland.

The procedures, performed on July 13, involved eight simultaneous surgeries four donor nephrectomies and four kidney transplants across five operating theatres between 7:00 am and 6:00 pm. The swap enabled four patients who were previously incompatible with their original donors due to blood-group mismatches or donor-specific antibodies to receive life-saving, compatible organs. Each pair had encountered distinct medical barriers to direct donation.

• Tsutsangla Pongen, 34, from Nagaland, needed a second transplant but possessed antibodies against her brother, Arikokba Pongen, 28.
• Abdul Rouf Bhat, 47, from Jammu & Kashmir, also awaiting a second transplant, was immunologically incompatible with his sister, Nazneen Rehman Bhat, 42.
• Shivani Khurana, 46, from Delhi, had developed antibodies against her husband, Varun Khurana, 49, following a past pregnancy and blood transfusion.
• Law Bahadur, 34, from Bihar, was blood-group incompatible with his wife, Nidhi Kumari, 36.

Utilising Alliance for Paired Kidney Donation (APKD) software alongside rigorous human leukocyte antigen (HLA) typing and cross-matching, specialists configured an optimal cross-donation loop: Varun Khurana donated to Tsutsangla Pongen; Arikokba Pongen donated to Law Bahadur; Nidhi Kumari donated to Abdul Rouf Bhat; and Nazneen Rehman Bhat donated to Shivani Khurana.

Because a four-way exchange of this magnitude is unprecedented, securing regulatory clearance required extensive documentation, multiple presentations, and a formal appeal to the High Court of Delhi before permissions were granted.

The surgical chain was led by Prof (Dr) Dinesh Khullar and Prof (Dr) Anant Kumar of Max Super Speciality Hospital, Saket, in collaboration with Dr Shafiq Ahmed of BLK-Max Hospital. All four recipients and donors have recovered well and have been discharged.

“Paired kidney exchange can open a new avenue for patients who have willing donors but are unable to undergo direct transplantation due to blood-group or immunological incompatibility. Careful HLA matching, cross-matching and immunological assessment are critical to identifying safe and viable donor-recipient combinations," said Prof (Dr) Dinesh Khullar from Department of Nephrology & Renal Transplant Medicine.

While Prof (Dr) Anant Kumar from Department of Urology & Kidney Transplantation said, “The success of this four-way exchange demonstrates what can be achieved when families are willing to participate, and the surgical team takes up the challenge to execute a meticulous & full-proof plan to do simultaneous procedures of compatible pairs so that swapping of kidneys is performed without mistakes.”

Dr. Shafiq Ahmed from Urology, Andrology & Renal Transplant added, “Expanding awareness and participation in kidney exchange programmes can help make better use of the limited pool of living donors and create more opportunities for patients who may otherwise continue to wait for a suitable kidney.”