# Comparison of Double Versus Single Renal Artery Anastomosis in Kidney Transplantation and Their Impact on Graft Survival, Surgical Outcomes, and Postoperative Complications

## TL;DR

This study compares kidney transplant outcomes using single versus double renal artery anastomosis and finds similar graft survival and function despite longer warm ischemia time in the double artery group.

## Contribution

The study provides regional data showing that double renal artery grafts are as effective as single artery grafts in kidney transplantation.

## Key findings

- Warm ischemia time was significantly longer in the double artery group, but graft function outcomes were comparable.
- Postoperative complication rates and one-year graft survival were similar between single and double artery anastomosis groups.
- Using kidneys with multiple arteries is safe and can help expand the donor pool in resource-limited settings.

## Abstract

Background: Kidney transplantation remains the preferred treatment for end-stage renal disease (ESRD), offering better survival and quality of life than dialysis. Anatomical variations such as double renal arteries, however, may increase the technical complexity of vascular anastomosis. Data comparing outcomes between single and double renal artery grafts are limited in our region. The purpose of this study was to compare the graft function, surgical outcomes, and postoperative complications of kidney transplant recipients who had a single renal artery anastomosis with those who had a double renal artery anastomosis.

Methods: This prospective comparative observational study was conducted at the Institute of Kidney Diseases (IKD), Peshawar, from April 2023 to April 2025. A total of 80 adult renal transplant recipients were included: 50 with single renal artery grafts and 30 with double renal artery grafts. Donor and recipient demographics, ischemia times, perioperative complications, graft function (serum creatinine, estimated glomerular filtration rate (eGFR), urine output, and delayed graft function (DGF)), and one-year graft survival were analyzed. Statistical analysis was performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA), with significance set at p < 0.05.

Results: Baseline donor and recipient characteristics were comparable between groups. Warm ischemia time was significantly longer in the double artery group (38.1 ± 9.2 vs. 32.8 ± 8.5 minutes, p = 0.01), while cold ischemia time showed a non-significant trend toward prolongation (47.5 ± 12.8 vs. 42.3 ± 11.2 minutes, p = 0.07). Graft function outcomes were similar, with no significant differences in serum creatinine at 12 months (1.48 ± 0.39 vs. 1.36 ± 0.35 mg/dL, p = 0.18), eGFR (56.1 ± 10.9 vs. 58.4 ± 11.6 mL/min/1.73 m², p = 0.39), urine output (3.0 ± 0.8 vs. 3.2 ± 0.9 L, p = 0.42), or DGF (16.7% vs. 12%, p = 0.58). Postoperative complications, including vascular thrombosis, urological issues, re-exploration for bleeding, and acute rejection, showed no significant differences. One-year graft survival was excellent in both groups.

Conclusion: Double renal artery anastomosis in kidney transplantation is safe and effective, with comparable graft function, complication rates, and survival to single renal artery anastomosis. Despite a modestly longer warm ischemia time, outcomes remained equivalent, supporting the use of kidneys with multiple renal arteries to expand the donor pool in resource-limited settings.