Out-of-pocket expenditure and financial implications of renal transplant in children at a not-for-profit tertiary care hospital in a low-middle-income country

Background: Renal transplant in children with chronic kidney disease has substantial financial implications on families from low and middle-income countries where health care resources are limited. The impact remains poorly quantified, creating a critical knowledge gap. This study aims to assess out-of-pocket health expenditure (OOPE) and its financial implications among families of children undergoing renal transplant.
Methodology: A hospital-based study was conducted in children with kidney disease who underwent transplant from November 2017 to January 2026. Catastrophic OOPE was defined as expenditure exceeding 10% of monthly per capita household expenditure. Statistical analysis was done using IBM® SPSS version 29.0.0.0. Continuous data were expressed as means and standard deviations (SD), and categorical data as numbers and percentages.
Results: A total of 16 children underwent kidney transplant. Mean age at ESKD was 11.75 ± 1.7 years; mean age at transplant was 12.63 ± 1.7 years. Over 9 years, only 3% (16/520) children who were provided an expenditure estimation returned for transplant. Of these, 2/16 had crowdfunding support, 5/16 had financial assistance from government funds, 6/16 had insurance, 14/16 made partial self-payments, and 5/16 were totally self-funded. Monthly income was less than INR 20,000 in 4/16, between INR 25-50,000 in 3/16, between INR 50,000-1,00,000 in 5/18, and more than INR 1,00,000 in 4/16.
The median number of admissions pre-transplant was 2 (IQR 1, 4) and post-transplant was 3 (IQR 1, 5). The median pretransplant admission expenses were INR 2,77,646 (IQR 50,231 - 4,65,619). The mean cost of donor nephrectomy was INR 1,70,000 ± 23,936 while the inpatient bill for recipient admission, including post-operative care was INR 5,66,906 ± 181,330. Following this, the mean monthly expense in the first year, given the high frequency of hospital visits, was INR 22,171 ± 6335. Apart from this, most children had readmissions in the first year with a median expense of INR 2,15,027 (1,60,381-2,37,215)
The mean OOPE was 32% (± 15). An OOPE of more than 10% of household expenditure was observed in 100% of caregivers; 62.5% had an OOPE exceeding 25%. At the time of this study, 3/16 were still in debt and were struggling to repay loans.
Conclusion: This study reveals the significant financial burden and catastrophic OOPE that persists even after transplant. Though the quality of life improves, hospital visits and monitoring for complications continue. The findings demonstrate that most families face significant financial hardship, incur catastrophic health expenditures, and continue to remain in debt much after.