Beyond the Operating Room: A Health-System Framework for Sustainable Kidney Transplant Care across Pakistan and Comparable Low- and Middle-Income Countries

Abstract

Kidney transplant care in low- and middle-income countries still prioritises getting patients to transplant over the systems needed to sustain long-term graft survival. This narrative review argues that graft survival is best understood as a health-system outcome rather than a purely surgical one, drawing on evidence from Pakistan, India, Iran, Brazil, and Türkiye. We searched major databases through July 2026 and grey literature through September 2026 for evidence on post-transplant maintenance care, funding, surveillance, and outcomes across these countries. We organised what we found around the World Health Organization's health-system building blocks. On the basis of our results, we propose the Graft Survivorship Framework: five interdependent domains covering lifelong access to immunosuppression and medication continuity, follow-up and surveillance infrastructure, service delivery and continuity of care, governance and funding, and equity-focused outcome tracking. The framework most directly applies to middle-income systems with established transplant programmes, and may serve as a guide for low-income countries as their programmes expand. In the published evidence we reviewed, no single country’s system addressed all five domains, but each illustrates a distinct policy approach, whether centralised funding, institution-driven care, or national outcome registries. Because these domains depend on one another, weakness in any one may undermine the rest, even when the others are strong. Translating this framework into context-specific policy, and testing it prospectively, may offer a practical way toward more durable and equitable transplant outcomes in comparable settings.