| Abstract|| |
This study compares outcomes and graft function of right and left grafts of deceased donor. We studied 120 kidney recipients from 60 deceased donors in Shiraz organ transplantation center from 1988 to 2004. We analyzed data regarding age, gender, side of grafts, duration of pre-transplant dialysis, hospital stay, serial creatinine levels, cold ischemic time, complications, graft function, patient survival rates, and post-operative complications. Recipients were divided into two groups: group 1 consisted of 60 recipients who received right renal graft (43 males, 17 females; mean age: 33.6 ± 7.3 years), and group 2 consisted of 60 recipients who received left renal graft (45 males, 15 females; mean age: 29.2 ± 6.4 years). No statistically significant differences were found in duration of pre-transplant dialysis, cold ischemic time, acute rejection rates, post-operative surgical and vascular complications' rates, hospital stay, renal function, and one year graft survival rates. We conclude that although it is advised to use left kidney from live donors because of longer vessel length, easier surgical technique and organ handling, and shorter ischemic time, we got the same outcome in left and right deceased renal grafts.
Keywords: Graft survival, kidney transplantation, left kidney, post-operative complications, right kidney
|How to cite this article:|
Salehipour M, Bahador A, Jalaeian H, Salahi H, Nikeghbalian S, Khajehee F, Malek-Hosseini SA. Comparison of Right and Left Grafts in Renal Transplantation. Saudi J Kidney Dis Transpl 2008;19:222-6
|How to cite this URL:|
Salehipour M, Bahador A, Jalaeian H, Salahi H, Nikeghbalian S, Khajehee F, Malek-Hosseini SA. Comparison of Right and Left Grafts in Renal Transplantation. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2021 Dec 8];19:222-6. Available from: https://www.sjkdt.org/text.asp?2008/19/2/222/39034
| Introduction|| |
Renal transplantation is the method of choice for treatment of patients with end-stage renal failure. Although the number of live-donor renal transplants has increased steadily over the past decade, deceased transplants continue to outnumber live-donor transplants by three to one, worldwide.  The results of deceased renal transplantation are dependent on many variables of the donors including age, gender, race, body size, cause of death, terminal renal function, comorbidities, and beating vs. non beating heart. ,
There is limited evidence suggesting that due to technical complications stemming from the disparity in the lengths of the left and right renal veins, , the renal left or right grafts may impact significantly the outcome. ,
However, in light of the substantial improvements in renal transplant outcomes achieved over the last decade, some studies have questioned whether left kidney transplantation continues to be a contemporary, independent predictor of early post-transplant graft survival. 
We aim in this the present study to compare the outcomes and graft function of right and left deceased renal grafts.
| Material and Methods|| |
We retrospectively analyzed the outcomes of 60 left-right pairs of deceased renal grafts transplanted into 120 recipients with end-stage renal failure in Shiraz organ transplantation center from 1988 to 2004. In order to ensure that all other donor factors were equally represented in the study groups, recipients were not included if one or both renal allografts were shipped to another center for kidney transplantation. The preservation fluid was the University of Wisconsin solution. The recipients immunosuppressive therapy included a calcineurin inhibitor (cyclosporine or tacrolimus), prednisolone, and either azathioprine or mycophenolate mofetil (MMF).
We studied the patients' demographic data, operative data, post-operative complications, medical complications, and renal allograft function prospectively recorded on a computerized integrated renal database. Duration of pre-transplant dialysis, length of hospitallization, cold ischemia times, serial serum creatinine levels, post operative complications, graft function, and survival rates were compared between the two groups. All transplant recipients were followed up until death or to the end of the study.
The transplant procedures were performed by 6 experienced transplant surgeons over the study period. The transplants were allocated evenly, and a standard operative procedure was employed by all the surgeons. In the absence of other factors (e.g. previous transplants, abdominal scarring, ipsilateral peritoneal dialysis catheters), the renal grafts were implanted on the contralateral side, i.e. right kidneys to the left and left kidneys to the right to allow medial positioning of the collecting system. Left kidneys were used where possible for the recipient who was judged to be more technically challenging (e.g. obese or previous pelvic surgery) because of the greater flexibility afforded by the longer vein.
| Statistical analysis|| |
Data were analyzed using the software package, SPSS for Windows release 13.0 (SPSS Inc., Chicago, Ill). Comparisons between the recipients of left and right donor kidneys were performed using Student's "t" test. Differences in proportions were evaluated by the chi-square test or Fisher's exact test, as appropriate. Death-censored graft survival curves, survival probabilities and estimated mean survival times were generated according to the Kaplan-Meier method. Differences in the survival curves between the two groups were evaluated using the log rank test. P values of 5% or less was considered statistically significant.
| Results|| |
Recipients were divided into two groups: group 1 consisted of 60 recipients (43 males, 17 females) who received right renal graft while group 2 recipients (45 males, 15 females) received left kidney. Donor characteristics were identical in both groups due to the inclusion only of kidney transplant recipient pairs in our study.
[Table - 1] shows the baseline characteristics of the recipients in both groups. There was no statistically significant difference in the mean age, sex ratio, preoperative creatinine, and duration of pre-transplant dialysis between the study groups. Furthermore, no statistical differences were observed with respect to hospitalization duration (22.7 ± 3.5 vs. 21.3 ± 2.9 days) and cold ischemic time (3.4 ± 1.2 vs. 3.6 ± 1.0 hours).
The complications observed within the first year of renal transplantation are also presented in [Table - 1]. No significant differences were observed between recipients of left and right kidneys, even when a composite of vascular, hemorrhagic, infective and ureteric complications was analyzed.
During the period of the study, 22 patients in the left kidney group developed acute graft rejection compared with 26 patients in the right kidney group (p = 0.4). Actuarial graft survival was comparable between the two groups (p = 0.5); respective death-censored graft survivals for right and left kidney recipients were 94 and 98% at 1 month, 88 and 96% at 3 months, and 80 and 84% at 12 months, respectively.
Postoperative recipient graft function as assessed by serial creatinine levels at 1, 3, and 12 months postoperatively revealed no significant difference; mean serum creatinine concentrations were similar in the right and left kidney recipient groups at 1 month (0.8 vs. 1.0 mg/dL, respectively, p = 0.9), 3 months (0.9 vs. 0.7 mg/dL, p = 0.8), and 1 year (0.8 vs. 1 mmol/L, p = 0.9). Finally, there were no statistically significant differences in patient survivals for right and left kidney recipients at 1, 3 and 12 months were n (p = 0.5).
| Discussion|| |
Previously, most surgeons preferred to do most nephrectomy procedures on the left side owing to technical difficulties and renal vessel length. It has been suggested that the shorter length of the right renal vein may make it more difficult to perform the venous anastomosis in right kidney deceased donor transplantation, especially in obese subjects in whom the iliac vessels are deep, thereby leading to an increased risk of surgical complications. 
The present study demonstrated that the deceased renal graft side did not appreciably impact on early post-operative outcomes. Moreover, recipients of right donor kidneys exhibited comparable renal allograft function and death-censored graft survival rates to those patients transplanted with left donor kidneys.
Our findings are supported by those of Roodnat et al  and Johnson et al  who similarly did not observe any difference in graft outcomes between left and right kidney recipients at their centers. Similar findings have also been reported for laparoscopic live donor renal transplant operations. , Shokeir et al suggested that the kidney with less function be chosen for donor nephrectomy regardless of anatomical considerations. 
However, these results contrast with those of the two previous UNOS Registry studies in the late 1980s/early 1990s, which demonstrated a graft survival benefit associated with transplanting left kidneys. , It is probable that recent improvements in transplant outcomes may have abrogated any benefit associated with donor kidney side.
Also, the technical challenges presented by the relatively short length of the right renal vein may be at least partially counterbalanced by difficulties presented by the more frequent anatomical variations in the left renal vein, particularly the greater frequency of additional renal veins and circumaortic left renal veins. 
In addition, previously Roodnat et al found that the one and most important avoidable risk factor for graft failure censored for death appears to be an increased cold ischemia time.  As we transplant right and left kidneys on two recipients by two transplantation teams, in two operating theaters simultaneously, the cold ischemic times were comparable in our patients for left and right kidney transplantation.
In conclusion, although left and right deceased donor renal grafts present different operative challenges, the present results suggest that the probability of early post-operative complications, delayed graft function, impaired early and medium-term renal allograft function, and graft and patient survival is comparable between left and right renal graft recipients.
| References|| |
|1.||El-Diasty TA, El-Ghar ME, Shokeir AA, et al. Magnetic resonance imaging as a sole method for the morphological and functional evaluation of live kidney donors. Br J Urol Int 2005;96(1):111-6. |
|2.||Roodnat JI, Mulder PG, Van Riemsdijk IC, Jzermans JN, van Gelder T, Weimar W. Ischemia times and donor serum creatinine in relation to renal graft failure. Transplantation 2003;75(6):799-804. |
|3.||Johnson DW, Mudge DW, Kaisar MO, et al. Deceased donor renal transplantation-does side matter? Nephrol Dial Transplant 2006; 21(9):2583-8. |
|4.||Janschek EC, Rothe AU, Holzenbein TJ, et al. Anatomic basis of right renal vein extension for deceased kidney transplantation. Urology 2004;63(4):660-4. |
|5.||Satyapal KS, Kalideen JM, Singh B, Haffejee AA, Robbs JV. Why we use the donor left kidney in live related transplantation. S Afr J Surg 2003;41(1):24-6. |
|6.||Gjertson DW. Multifactorial analysis of renal transplants reported to the United Network for Organ Sharing Registry. Clin Transpl 1992;:299-317. [PUBMED] |
|7.||Feduska NJ Jr, Cecka JM. Donor factors. Clin Transpl 1994;:381-94. [PUBMED] |
|8.||Swartz DE, Cho E, Flowers JL, et al. Laparoscopic right donor nephrectomy: Technique and comparison with left nephrectomy. Surg Endosc 2001;15(2):1390-4. |
|9.||Liu KL, Chiang YJ, Wu CT, Lai WJ, Wang HH, Chu SH. Why we consistently use the left donor kidney in living related transplantation: Initial experience of right laparoscopic donor nephrectomy and comparison with left nephrectomy. Transplant Proc 2006;38 (7):1977-9. |
|10.||Shokeir AA, Gad HM, el-Diasty T. Role of radioisotope renal scans in the choice of nephrectomy side in live kidney donors. J Urol 2003;170(2.1):373-6. |
|11.||Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV. Left renal vein variations. Surg Radiol Anat 1999;21(1):77-81 |
Assistant Professor of Urology, Fellowship of Renal Transplantation, Shiraz Organ Transplantation Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz
[Table - 1]