Expanding boundaries: The evolution and future of living donor kidney transplantation

Living donor kidney transplantation (LDKT) has evolved into a globally adopted clinical practice, driven by improvements in donor selection, immunological compatibility, and perioperative care. These advances have contributed to enhanced donor safety and improved early graft outcomes. Still, its uptake remains limited worldwide, influenced by differences in clinical infrastructure, surgical expertise, and programmatic priorities. A central procedural consideration in LDKT is the choice of kidney for procurement, right or left. Left donor nephrectomy is generally preferred due to favorable vascular anatomy, yet right-sided procurement is often necessary in the presence of anatomical variations. While some studies report higher rates of early complications with right-sided nephrectomy, including delayed graft function and early graft loss, long-term outcomes appear comparable. The evaluation of laterality, however, varies significantly across centers and is often shaped more by institutional practice than by comparative evidence. In this editorial, we review key clinical and technical advances that have improved the safety and outcomes of LDKT, including immunological matching, donor selection, perioperative strategies, and early graft performance. We then critically examine the role of kidney laterality in donor nephrectomy, highlighting how anatomical complexity and procedural risk continue to shape clinical decision-making.