Contemporary Practice of Right Living Donor Nephrectomy in the United States

Left-sided kidneys are preferred for living donor kidney transplant (LDKT) because their longer renal vein leads to greater technical ease. Nevertheless, right-sided nephrectomies are performed when favorable for donors. We evaluated national and center-level trends in right living donor nephrectomy.

We used SRTR data to identify all LDKTs from 1995-2024 and calculated annual proportions of right kidneys. Then analyzing the contemporary 10-year period (2015-2024), we calculated the Pearson correlation coefficient between center-level LDKT volume and proportion of right-sided nephrectomies. We also assessed the effect of Kidney paired donation (KPD) on proportion of right kidneys used at the center and national levels. We also compared the incidence of delayed graft function (DGF) and 90-day graft failure.

The proportion of right-kidney LDKTs decreased from 27% in 1995 to 10%-12% in the contemporary period. Individual centers varied greatly in proportion of right LDKTs, ranging from 0%-37%, with no meaningful correlation between center-level LDKT volume and proportion of right-sided donor nephrectomies (r² = 0.02). KPDs involved a greater proportion of right kidneys compared to direct donations (12% vs. 11%, p = 0.003). Additionally, even in the contemporary era, right-sided LDKTs had higher incidence of DGF (2.4% vs. 1.3%) and 90-day graft failure (8.7% vs. 5.2%) compared to left-sided LDKTs (both p < 0.01).

Center-level variation in right LDKTs likely reflects different thresholds in accepting anatomic complexity or split function and is independent from overall center volume. Further, despite advances in laparoscopic LDKT, right kidneys remain associated with early graft dysfunction in the contemporary era.