Why is the native kidney left in place during a kidney transplant?

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Last updated: March 24, 2026 • View editorial policy

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Why Native Kidneys Are Left During Transplantation

The native kidneys are routinely left in place during kidney transplantation because removing them adds significant surgical risk and morbidity without providing benefit in most patients, and the native kidneys may retain residual function that contributes to overall renal clearance.

Standard Surgical Practice

The transplanted kidney is placed in the iliac fossa (lower pelvis) in an extraperitoneal location, making it surgically accessible and allowing the native kidneys to remain undisturbed in their retroperitoneal position 1. This approach:

  • Minimizes operative time and blood loss by avoiding the additional dissection required to access the native kidneys in their deep retroperitoneal location
  • Reduces perioperative complications including bleeding, infection, and prolonged anesthesia exposure
  • Preserves any residual native kidney function, which can contribute meaningfully to overall renal clearance even in patients with end-stage renal disease 2

Residual Native Kidney Function

Even in patients with chronic kidney disease requiring transplantation, native kidneys may contribute up to 23% of total renal function post-transplant (with the graft providing approximately 77% on average) 2. This residual function:

  • Provides additional clearance capacity during the early post-transplant period when graft function may be delayed
  • Offers a safety margin if the transplanted kidney experiences acute dysfunction or rejection
  • Can maintain some endocrine functions including erythropoietin production

Specific Indications for Native Nephrectomy

Native kidney removal is performed only when specific complications arise 1:

Symptomatic Disease (Most Common)

  • Recurrent infections (36% of nephrectomy indications in transplant recipients with ADPKD) 1
  • Intractable pain (27% of indications) 1
  • Recurrent hematuria (12% of indications) 1

Space Requirements

  • Massive polycystic kidneys that physically prevent placement of the transplant graft (15% of indications) 1
  • This is primarily relevant in autosomal dominant polycystic kidney disease (ADPKD)

Malignancy Concerns

  • Suspected renal cell carcinoma in the native kidney (4% of indications) 1

Refractory Hypertension

  • Treatment-resistant hypertension mediated by renin-angiotensin system activation from diseased native kidneys 3, 4
  • Native nephrectomy in selected hypertensive transplant patients can reduce mean arterial pressure and increase allograft plasma flow by 77% while decreasing vascular resistance by 55% 4
  • The native kidneys' hypertensive effect appears mediated through the renin-angiotensin system, as captopril can reproduce similar hemodynamic improvements without nephrectomy 4

Timing Considerations

When native nephrectomy is required, it can be performed:

  • Before transplantation (staged approach) in patients with severe symptoms or space constraints
  • Simultaneously with transplantation (increases operative complexity and risk)
  • After transplantation (allows assessment of which patients truly require the procedure) 1

In ADPKD patients, 59% ultimately required native nephrectomy, with 68% needing bilateral removal 1. However, this means 41% never required nephrectomy, supporting the conservative approach of leaving native kidneys unless complications develop.

Clinical Pitfalls

  • Do not assume all transplant recipients need native nephrectomy—the majority do not 1
  • Monitor for post-transplant hypertension that may be native kidney-mediated, particularly in patients with renovascular disease or ADPKD 3, 4
  • Recognize that native kidney contribution decreases over time in patients with organic nephropathy, but initial preservation of function justifies leaving them in place 2
  • In preemptive transplant recipients (not yet on dialysis), native kidneys with creatinine clearance >30 mL/min may provide meaningful ongoing function 2

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.