Donor Anatomical Variations and Surgical Complexity in Living-Donor Renal Transplantation: A Multi-Center Experience in The Iraqi Kurdistan Region

Abstract

Background: Kidney transplantation remains the optimal treatment for end-stage renal disease (ESRD), with living-donor transplantation offering superior graft survival and quality of life compared to deceased-donor transplantation. Renal vascular anatomical variations are common, with multiple renal arteries reported in literature to be as high as18–30% of the general population, potentially increasing surgical complexity and affecting outcomes. In the Iraqi Kurdistan Region, living-donor transplantation is the only form of kidney transplantation available. However, published data on donor anatomical variations and their surgical implications in this population are limited.
Aim: To evaluate the impact of donor anatomical variations on surgical complexity and perioperative outcomes in living-donor renal transplantation in the Iraqi Kurdistan Region.
Methods: This retrospective case series included 52 living kidney donors and their corresponding recipients who underwent renal transplantation at the Duhok Kidney Disease and Transplant Center and the Department of Urology at Rizgary Teaching Hospital between February 2025 and December 2025. Preoperative CT angiography was used to assess renal vascular anatomy. Operative details, including operative time, anastomosis technique, and complications, were recorded. Chi-square tests, logistic regression, linear regression, and Cox regression were used to examine factors associated with surgical complexity and outcomes.
Results: In this cohort, multiple renal arteries were present in 40.4% of donors, with 30.8% having unilateral and 9.6% having bilateral variations. Meanwhile, multiple renal veins were present in 23.1% of donors. The mean donor operative time was 98.1 minutes, while the mean recipient operative time was 126.8 minutes. Multiple renal arteries were significantly associated with prolonged operative time (β = 31.25 minutes, p = 0.001) and increased risk of intraoperative bleeding complications (OR = 3.08, p = 0.007). DSA Class II positivity was the strongest predictor of recipient complications (OR = 6.00, p = 0.003). A Donor Anatomical Complexity Score was developed from the weighted contribution of the anatomical variations examined in the study.
Conclusion: Donor anatomical variations, particularly multiple renal arteries, were common in this cohort and were associated with greater surgical complexity. With appropriate preoperative imaging and surgical expertise, however, these variations were not associated with worse short-term graft outcomes.
Preoperative CT angiography is important for defining vascular anatomy and planning the operation.