Building pragmatic transplant immunobiology in Sri Lanka: a concise review with an LMIC lens

Sri Lanka's kidney transplantation programme has matured within a resource-constrained public health system and has achieved short-term outcomes that appear comparable to published ranges from similar middle-income programmes, despite major limitations in real-time transplant immunobiology support. However, increasing recipient sensitisation, prolonged dialysis vintage, and a growing deceased-donor programme demand more reliable immunological risk assessment to improve equity and graft outcomes. This pragmatic narrative review summarises the minimum immunobiology package that can support safer kidney transplantation in low- and middle-income settings, using Sri Lanka as an example. Key concepts are explained in simple operational terms, including sensitisation and antibody screening (PRA, including the Zora assay), single-antigen bead testing and donor-specific antibody interpretation, practical use and limitations of virtual crossmatch when donor HLA data are incomplete, and the continuing role of CDC crossmatch where flow-cytometry crossmatch is unavailable. The review also highlights why unexpected early rejection may still occur even when HLA-based testing appears reassuring, and why over-reliance on any single assay can be misleading. Finally, a staged roadmap is proposed—prioritising feasible upgrades, quality assurance, workforce development, and national coordination—to progressively strengthen transplant immunobiology while preserving affordability, fairness, and sustainability. This is a pragmatic narrative review informed by consensus guidance and key peer-reviewed literature, synthesised to prioritise actionable, scalable immunobiology components for low- and middle-income settings.