Why are kidney transplants often performed on the right side?

Kidney Transplant Placement: Right vs. Left Side

The Question is About Recipient Placement, Not Donor Selection

Kidney transplants are typically placed on the right side of the recipient's pelvis (right iliac fossa) because the right internal iliac vein anatomy provides more direct and favorable vascular access for anastomosis, though both sides can be used successfully. 1

Anatomical Rationale for Right-Sided Recipient Placement

Vascular Considerations

• The right side is preferred in the absence of contraindications or prior pathology because it offers more direct anatomy for vascular anastomosis. 1
• The right iliac vessels provide a straighter, more accessible surgical approach for connecting the donor kidney's renal artery and vein to the recipient's iliac vessels. 1
• The inferior vena cava (IVC) lies on the right side of the aorta, making right-sided placement anatomically more straightforward for venous drainage. 2

When to Use the Left Side Instead

• If the right side has pathology that limits transplant placement (such as iliac vessel disease, prior surgery, or vascular reconstruction), the left side should be used. 1
• If one side has existing vascular access (such as a catheter) that can be accommodated but the other side is needed for future arteriovenous access creation, place the transplant on the side with the catheter to preserve the other side. 1
• Prior transplants on one side may necessitate using the contralateral side for subsequent transplantation. 1

Common Pitfalls to Avoid

Pre-operative Assessment

• Always evaluate both iliac vessels with imaging before surgery to identify stenosis, atherosclerotic disease, or anatomical variants that could complicate anastomosis. 1, 3
• Femoral or iliac vessel pathology is an absolute contraindication to ipsilateral transplant placement. 1
• Document any prior surgeries, pacemakers, or central venous interventions that may have caused central stenosis. 1

Preserving Future Access Options

• Consider the patient's ESKD Life-Plan and preserve vessels for potential future vascular access needs if the transplant fails. 1
• If a patient requires dialysis access while awaiting transplant function, place catheters strategically to avoid compromising the transplant site. 1

Technical Surgical Considerations

Standard Placement Approach

• The donor kidney (whether from left or right side of donor) is placed extraperitoneally in the recipient's iliac fossa. 4
• The renal artery is anastomosed to the recipient's external or internal iliac artery. 3
• The renal vein is anastomosed to the recipient's external iliac vein. 3
• The ureter is implanted into the bladder. 4

Donor Kidney Selection (Separate from Recipient Side)

• When procuring from living donors, the left kidney is generally preferred because its longer renal vein (6-10 cm vs. 2-4 cm for right) facilitates easier anastomosis during implantation. 5, 2
• The right donor kidney should be selected when it is clearly smaller, has lower function, or when the left kidney has anatomical abnormalities or complex vascular anatomy (≥3 arteries). 5
• Early studies showed increased venous thrombosis rates with right donor kidneys due to the very short right renal vein, though experienced surgeons can perform right nephrectomy safely. 5, 6

Clinical Outcomes

Safety Profile

• Both right and left recipient placement sites have equivalent outcomes when performed by experienced surgeons without contraindications. 7
• Graft thrombosis risk is primarily related to the donor kidney's vascular anatomy (particularly short right renal veins) rather than the recipient placement side. 6
• Conversion rates and complications are similar for both recipient sides when anatomy is favorable. 7