Introduction: In the beginning of pandemic, we emphasized on “the benefit to few versus risk to many” as a caution for continuing elective transplantation in resource limited nations like India.

Methods: Here we summarize all our research experience during the pandemic.

Results: We reported the comparative impact of pandemic from India in single center, national wide, and global observatory data on organ donation and transplantation. There was 50% decline in deceased donation transplantation in India contrasting with America, which was able to cope with the initial decline in transplants via a well-equipped deceased donation system. We contributed to National Organ and Tissue Transplant Organization (NOTTO), Transplant Specific Guidelines for COVID-19, NOTTO COVID-19 Vaccine Guidelines, NOTTO guidelines for Vaccine-induced thrombotic thrombocytopenia in organ donation, and consensus statement for kidney transplant recipient (KTR) and donor with a previous diagnosis of COVID-19. We first time reported that mortality rates in Southeast Asian KTR (n=250) with COVID-19 infection appear to be higher than those in non-immunosuppressed patients in our multicenter project.  In nationwide data, we reported mortality in early kidney transplant recipients to be lower, and waitlisted patients to be higher which suggests, immunosuppression as per se is not an important factor in halting transplantation. We reported a different clinical spectrum of COVID-19 amongst KTR with similar mortality between the two waves. We were the first one to report safety of remdesivir (n=57) and convalescent plasma therapy (n=10) in organ transplant recipients. We reported the largest retrospective, multicentre, cohort study of KTR (n=31) from living donors who recovered from COVID-19, KTR (n=372) after recovery from COVID-19, COVID-19-associated mucormycosis (CAM) with 4.4% incidence of CAM and 26.2% mortality, and with reoccurring SARS-CoV-2 infection(n=13), with 46% mortality. Our reports suggest that transplantation from COVID-19 donors may be feasible and safe, at least in short-term follow-up. In general, continuing a standard immunosuppression regimen may be reasonable, except in cases of inadvertent transplantation with active SARS-CoV-2. We reported COVID-19 vaccine safety with suboptimal efficacy in KTR and dialysis patients in a single-center experience. More research is needed to guide the optimal approach to a vaccination before and after transplantation.

Conclusion: We are continuing our research on vaccine efficacy, booster doses, and follow-up sequelae. Further policy-making and preparedness are required to safeguard the most vulnerable areas of the world to minimize the impact of any future pandemic on transplantation practices.