The evolving deceased donor kidney transplantation programme in Sri Lanka: current landscape, constraints, and next steps.

Deceased donor kidney transplantation (DDKT) is an essential strategy to improve access to kidney replacement therapy in low- and middle-income countries (LMICs), where haemodialysis capacity remains insufficient and long-term peritoneal dialysis is under-utilised. In Sri Lanka, deceased donation has evolved from sporadic, centre-driven activity towards a more structured national programme with clearer policy direction, defined retrieval zones, and gradually standardised clinical workflows. However, safe expansion of DDKT requires more than policy development. It depends on practical investment in implementation systems, including protected transplant coordination roles, secure and reliable information platforms, and timely access to quality-assured immunobiology services. At present, consistent national execution is constrained by the incomplete availability of three key enabling components: (i) a real-time national transplant waitlist with accurate candidate status, (ii) an end-to-end organ offer and acceptance workflow that produces a permanent audit trail, and (iii) time-critical immunobiology capacity to support compatibility assessment for each deceased donor offer. In this context, zone-based coordination with standardised but largely manual allocation processes continues to function as a pragmatic transitional safety framework. Nevertheless, this model limits reproducibility, equity monitoring, and systematic programme learning. This Perspective summarises the current policy and operational environment, identifies predictable bottlenecks across the donation-to-transplant pathway, and proposes a staged systems roadmap that prioritises safety and auditability before automation. Key priorities include structured manual allocation processes with mandatory documentation and key performance indicator (KPI) reporting, development of a minimum viable national registry with a secure offer workflow, and phased strengthening of immunobiology services to enable gradually automated and quality-assured national allocation. The Sri Lankan experience offers practical and potentially transferable lessons for LMIC transplant programmes seeking to scale deceased donor transplantation while maintaining patient safety, equity, and public trust.