Journal of Medical Imaging and Radiation Oncology  (2020) –

MEDICAL IMAGING—ORIGINAL ARTICLE

Assessment of renal vascular anatomy on multi-detector

computed tomography in living renal donors

Journal of Medical Imaging and Radiation Oncology

Damien C O’Neill,1 Blathnaid Murphy,1 Emma Carmody,1 Luke Trench,1 Ruth Dunne,1 Michael J Lee,1
Dilly Little and Martina M Morrin1
2

1 Department of Radiology, Beaumont Hospital, Dublin, Ireland

2 Department of Urology and Transplant, Beaumont Hospital, Dublin, Ireland

DC O’Neill MB, FFR, RCSI; B Murphy MB, Abstract

FFR, RCSI; E Carmody MB, FFR, RCSI;
L Trench MB; R Dunne MB, FFR, RCSI;
MJ Lee MB, FFR, RCSI; D Little MB, FRCS
(Urol); MM Morrin MB, FFR, RCSI.
Correspondence
Dr Damien C. O’Neill, Department of
Radiology, Beaumont Hospital, Dublin 9,
Ireland.
Email: damienconeill@rcsi.com
Conflict of interest: None
Submitted 8 March 2020; accepted 23 April
2020.
doi:10.1111/1754-9485.13050
Background: Prospective renal donors are a select population of healthy indi-
viduals who have been thoroughly screened for significant comorbidities
before they undergo multi-detector computed tomography angiography and
urography (MDCT).
Purpose: The aim of this study is to describe the anatomy of potential living
renal donor subjects using MDCT over a 2-year period. The primary objective
is to identify the renal arterial anatomy variations, with a secondary objective
of identifying venous and collecting system/ureteric variations.
Materials and Methods: A prospective study was performed of prospective liv-
ing kidney transplant donors at a national kidney transplant centre. Study
inclusion criteria were all potential kidney donors who underwent MDCT during
the living-donor assessment process over a 2-year period.
Results: Our cohort included 160 potential living donors who had MDCT; mean
age was 45.6 years (range, 21–71). Two renal arteries were identified on the
left in 40 subjects (25%) and on the right in 42 subjects (26.3%). A total of 3 or
more renal arteries were identified on the left in 7 subjects (4.4%) and on the
right in 7 subjects (4.4%). On the left, the distances between multiple arteries
ranged from 1 mm to 43 mm, and on the right, they were 1 mm to 84 mm.
Conclusions: Conventionally described anatomy was only seen on the left side in
70.6% and 69.4% on the right side of subjects. Single renal arteries are seen in
54.4% showing that conventional anatomy has a relatively low incidence.

Key words: donor nephrectomy; kidney transplantation; transplantation; vas-

cular anatomy.

offers an opportunity to overcome organ shortages and

Background
Renal transplantation is the treatment of choice for
patients with end-stage renal disease (ESRD),1 who are
medically and surgically fit for transplantation as it
improves the quality of life and survival recipients.
Quality-adjusted life-years (QALYs) gained from renal
transplantation are more favourable than maintaining
these patients on haemodialysis or peritoneal dialysis.2-
4
Only a minority of patients with ESRD receive kidney
transplants because of the limited availability of
deceased donor organs.5 Globally, renal transplant units
are developing their ‘living-donor’ programmes to
increase the availability of kidneys for patients requir-
ing transplantation.6,7 Living-donor renal transplantation
is associated with excellent long-term graft survival
among recipients. Moreover, living-donor grafts have
improved long-term survival compared to deceased
donor grafts as the duration of ischaemia is minimal
in the former, the procedure is usually elective, recipi-
ents’ health has been optimized, and transplanta-
tion can be performed in patients that are pre-emptive
for dialysis.5,8
Living-donor assessment process
In the Republic of Ireland and UK, the living-donor
assessment is sub-divided into three stages, described
previously.6

© 2020 The Royal Australian and New Zealand College of Radiologists 1

DC O’Neill et al.
A thorough and accurate evaluation of prospective
renal donors is important for planning transplant sur-
gery in an effort to minimize perioperative complica-
tions. In prospective renal living donors, multi-detector
computed tomography (MDCT) including CT angiography
and CT urography is the standard imaging modality for
accurately characterizing renal vasculature and
anatomy.9,10
Accurate knowledge of the renal vasculature and anat-
omy is needed to guide the transplant surgeon in deter-
mining the suitability of a potential donor and to
minimize the morbidity and mortality associated with
donor nephrectomy.11 Pre-operative vascular mapping
prior to laparoscopic donor nephrectomy helps minimize
surgery-related morbidity from this elective proce-
dure.12,13
CT angiography is highly accurate in identifying the
number and calibre of renal arteries as well as the vessel
branching pattern (Fig 1).11,14 CT also provides informa-
tion regarding renal venous anatomy, including the renal
vein, adrenal vein, gonadal vein and lumbar veins.15
Renal vascular anatomy can be extremely variable,
with accessory arteries, early branching, polar branching
and venous variation being very common. Single arteries
arising from the aorta are reported in 80-85%, double
renal arteries can be seen in up to 15%,16 with three or
more renal arteries reported in approximately 1%.17
Multiplicity of renal veins is a frequent occurrence.18
Incidental renal and non-renal pathologies are fre-
quently encountered and described previously, with 42%
of donors having incidental findings.6 These can result in
further investigations and imaging with some incidental
malignancies uncovered.
The aim of this study is to describe the anatomy of
potential living renal donor subjects using multi-detector
computed tomography angiography and urography
(MDCT). The primary objective is to identify the renal
arterial anatomy variations, with a secondary objective
of identifying venous and collecting system/ureteric
variations.
(a)
Fig. 1. The 40-year-old female prospective renal donor. 3D volume-rendered CT and coronal maximum-intensity projection demonstrating three right-sided
(R1, R2, R3) and two left-sided (L1, L2) renal arteries.
2 © 2020 The Royal Australian and New Zealand College of Radiologists
Methods
A review of the prospectively maintained renal transplant
database was performed. Study inclusion criteria were all
potential kidney donors who underwent MDCT during the
living-donor assessment process over a 2-year period
(January 2015 and January 2017). Exclusion criteria
were potential living donors that did not proceed to
MDCT. The protocol underwent Institutional Review
Board review and was granted approval.
Multi-detector computed tomography protocol
In our institution, a low-dose non-contrast CT followed by
a combined arterial and urographic phase study is per-
formed. Computed tomography scans are performed
using a 16-slice MDCT scanner (Sensation 16, Siemens
AG, Erlangen, Germany) or a 128-slice MDCT scanner
(Philips 128, Phillips Healthcare, Bothell, WA, USA). For
the procedure, a low-dose non-contrast CT at 100 mA
from the xiphisternum to the pubic symphysis is first per-
formed to primarily evaluate for stone disease. Next,
50 mL of iopamidol (Niopam 300) is manually injected
into a peripheral intravenous catheter to provide contrast
opacification of the urinary tracts when excreted, which is
followed by 100 mL of iopamidol (Niopam 370) pump-in-
jected at 5 mL/s after a further 10 min. This is bolus
tracked when triggered images are acquired from the
xiphisternum to the pubic symphysis. This results in a
combined study of the arterial system from the pump
injection of contrast and of the urinary system from the
hand contrast injection 10 min previously. All image data
are reconstructed with a body soft-tissue algorithm in
1-mm-thick and 3-mm-thick sections. All CT angiograms
are interpreted in axial, sagittal and coronal reformations.
Image analysis
Images from each CT examination were interpreted by
the primary reporter at the time of the examination. For
(b) (c)

the purposes of this study, initial assessment of all eligi-
ble MDCTs was performed by two radiology residents
(EC, BM). Subsequent review of all imaging by a fellow-
ship-trained radiologist (MM) was performed. For image
analysis, thin slice (1 mm) multi-planar reformats were
used with maximum-intensity-projection (10 mm) ren-
dering used as an adjunct display where required.
Parameters assessed in this study were as follows:
• The number of renal arteries arising from the aorta,
when two of more renal arteries were identified the
distance between the most superior and inferior renal
arteries, was measured to predict the need for more
complex vascular reconstruction.
• The number of veins draining to the inferior vena cava
(IVC) was recorded.
• Vascular anomalies such as fibromuscular dysplasia
(FMD), renal artery stenosis, the presence of athero-
matous disease and aneurysms were recorded.
• Variants of ureteric anatomy such as duplex ureters
and the point of confluence were noted.
Results
During the study period, 160 MDCTs were performed, all
of which were diagnostic.
51.25% (n = 82) of subjects assessed were female
and 48.75% (n = 78) male. The mean age of the cohort
was 45.6 years (range 21–71).
Renal arterial variations
In our cohort, 70.6% (n = 113) had single left renal
arteries and 69.4% had a single right renal artery. Single
renal arteries bilaterally were identified in 87 subjects
(54.4%). Two renal arteries were identified on the left in
40 subjects (25%) and on the right in 42 subjects
(26.3%). A total of 3 or more renal arteries were identi-
fied on the left in 7 subjects (4.4%) and on the right in 7
subjects (4.4%) (Table 1). In one patient, an accessory
replaced left renal artery arose from the coeliac trunk.
In the screened cohort, 80 subjects (50%) proceeded
to kidney donation. In 77 of these (96%), the left kidney
was used for transplantation. Of the 3 subjects that pro-
ceeded to donation of a right kidney, one of these was
Table 1. Breakdown of the number of renal arteries on either side and
whether they proceeded to donation
Renal arterial variations (n = 160) (number of subjects)
Number of renal arteries 1 2
Left donated 113 40
54 20
Right donated 111 42
3 0
© 2020 The Royal Australian and New Zealand College of Radiologists
Renal vascular anatomy in living renal donors
due to the presence of fibromuscular dysplasia in the
right renal artery. In the other 2 subjects, the right kid-
ney was used due to surgeons’ preference.
On the left, the distances between multiple arteries
ranged from 1 to 43 mm, and on the right, they were 1
to 84 mm (Tables 2 and 3).
The median length of the right renal artery was
44 mm (IQR 28–60) and 34 mm (IQR 19–49) on the left.
Renal veins
Single left renal veins were identified in 80% (n = 128)
of our cohort. 18% (n = 28) had 2 left renal veins, and
the remaining 2% (n = 4) had three renal veins.
Single right renal veins were identified in 71%
(n = 122), 20% (n = 33) of the cohort had 2 right renal
veins, and 3% (n = 5) had three renal veins. Table 4
A retro-aortic course of the left renal vein was identi-
fied in nine subjects, three of whom proceeded to dona-
tion. A circum-aortic left renal vein was identified in six
subjects, four of whom proceeded to donation.
Vascular pathology
Fibromuscular dysplasia was identified in four subjects
(2.5%) in our cohort none of which were known about
pre-assessment with MDCT. One of these kidneys was
used for donation (Figure 2).
Renal artery ostial atherosclerosis either in the aorta
at the level of the renal artery or within 1cm of the origin
of the renal artery was identified in five cases.
Atherosclerotic plaque without a resultant stenosis
(of> 30%) was identified in 34 subjects in the remainder
of the renal arteries was identified.
In two subjects, three renal artery aneurysms were
identified (mean size 4.3 mm), both of whom had FMD.
The largest aneurysm was 6mm arising from an upper
pole division (Fig 3). The other aneurysms measured
3 mm and 4 mm, respectively, and were at branch points
in the renal hilum in either kidney of one individual.
These underwent surveillance imaging and were stable.
None of these kidneys were used for donation. None of
these aneurysms required intervention.
Table 2. Distance between the renal arteries when multiple – Left
LEFT Kidney: 2 or more renal arteries, n = 47
Total distance (mm)† Total Range (mm)
<2 3–5 6–10 10–20 >20
3 >3
2 arteries 17 8 8 6 3 42 1–43
6 1 3 arteries 0 1 2 1 0 4 1–35
3 0 >3 arteries 0 0 1 0 0 1 9–27
6 1
0 0 †Between the most superior and inferior renal arteries when> 2 ves-
sels present.
3
DC O’Neill et al.

Table 3. Distance between the renal arteries when multiple – Right systems were used for kidney donation. In two patients
with partial duplex systems, the contralateral kidney was
RIGHT Kidney: 2 or more renal arteries, n = 49
used for donation.
Total Distance (mm)† Total Range (mm)

<2 3–5 6–10 10–20 >20 Discussion

2 arteries 22 8 4 4 4 42 1–35 Conventional renal vascular anatomy comprises of a sin-
3 arteries 0 1 1 3 1 6 1–84 gle vessel arterial supply and venous drainage of each
>3 arteries 0 0 1 0 0 1 4–24 kidney. In reality, there is wide anatomical variation. In
our study, this conventionally described anatomy was
†Between the most superior and inferior renal arteries when> 2 ves-
only seen on the left side in 70.6% and 69.4% on the
sels present.
right side of subjects. 87 subjects (54.4%) had single
renal arteries bilaterally, showing that ’normal’ anatomy
Table 4. Breakdown of the number of renal veins on either side and has a relatively low incidence. Other studies have
whether they proceeded to donation reported the incidence of accessory renal arteries at
19% at 2 cm from aorta on CT14 and of the presence of
Renal vein variations (n = 160) (number of subjects)
multiple renal arteries/early branching in 27%.15 The rel-
Number of renal veins 1 2 3 ative increased incidence of renal arteries is likely due to
a combination of slightly differing definitions of multiple
Left donated 128 28 4 renal arteries and early branching, determined by the
63 11 3
transplant surgeons in our institution.
Right donated 122 33 5
We identified one case of a replaced left renal artery
3 0 0
arising from the coeliac trunk. This was the only case of
a replaced renal artery that we identified. Subsequently,
this kidney was not used after discussion at the national
living-donor multidisciplinary team meeting.
On the left, the distances between arteries ranged
from 1 to 43 mm, and on the right, they were 1 to
84 mm. The decision to use kidneys with multiple sup-
plying renal arteries is determined by the following: the
number of renal arteries and the distance between these
arteries – when there is a long distance between acces-
sory arteries creating an arterial anastomosis becomes
more challenging. The relative size of the renal arteries
plays a role as tiny branches typically heading to a polar
region can usually be sacrificed. Our local transplant sur-
geons sacrifice where necessary accessory renal arteries
that measure up to 2 mm, measured on the pre-opera-
tive MDCT. Intra-operatively these arteries are identified
to confirm the MDCT findings, and if reconstruction is not
possible, then the artery is sacrificed.
The right renal arteries are longer that the left. As the
renal vein also needs to be anastomosed to the recipient,
the left kidney is typically used for nephrectomy and
donation. In 2 subjects in our cohort, the right kidney
was used due to vascular variations identified on MDCT.
Fibromuscular dysplasia (FMD) has a reported inci-
Fig. 2. Coronal-oblique reformat of the renal arteries demonstrating a dence of 4.4% in prospective renal donors, and it is the
beaded appearance of the middle portion right renal artery, consistent with
second most common cause of renovascular hyperten-
fibromuscular dysplasia.
sion after atherosclerotic disease.19 The presence of
fibromuscular dysplasia is not a contra-indication to
transplant.20 Typically, if FMD is identified unilaterally
that kidney would be chosen for transplant. Our cohort
Ureters
had one such case. The incidence in our cohort was
There were 2 complete right-sided duplex systems, 2 2.5%, which is slightly lower than other published litera-
partial right-sided duplex systems and 2 partial left-sided ture, likely due to the lower sensitivity of CT for FMD.
duplex systems. None of the kidneys with duplex Andreoni et al.19 reported an incidence of 4.4%;

4 © 2020 The Royal Australian and New Zealand College of Radiologists


(a)
Fig. 3. The 34-year-old female prospective
renal donor. 3D volume-rendered CT demon-
strating a 6mm aneurysm of an upper pole
branch of the right renal artery.
however, they used digital subtraction angiography,
which is the gold standard. CT angiography can underes-
timate the incidence of FMD particularly in the mid and
distal renal artery in mild disease.
Renal artery aneurysms (RAA) incidence on CT is
reported at approximately 0.7%.21 Accepted indications
for treatment of RAA include the following: size> 2 cm,
medially resistant hypertension, presence in females of
child bearing age, thromboembolism, dissection and rup-
ture.22 RAA were identified in 1.9% of our cohort. None
of these met the criteria for intervention. None of these
kidneys were used for donation. When present and crite-
ria for treatment have been met, RAA can be treated sur-
gically with auto-transplantation. More recently, novel
endovascular techniques have been used with increasing
frequency.23
Ostial atherosclerosis can make cross-clamping of a
renal artery more difficult, and this was present in 3.1%
of our cohort (n = 5). When calcified ostial disease is
present, our transplant surgeons do not typically use
that kidney for donation, even if the no associated
stenosis is present. None of the five subjects in our
cohort with ostial calcified disease proceeded to dona-
tion. The presence of bilateral renal arterial calcification
is a criterion for exclusion from donation.24 However,
the identification of atherosclerotic calcification in a
small vessel can be challenging and is likely underre-
ported in our cohort. The presence of distal atheroscle-
rosis is less of an issue from a technical point of view
however may indicate early vascular disease in that kid-
ney. None of our cohort with mid/distal vessel
atherosclerosis underwent further imaging investigations
based on the MDCT findings. Further investigation with
magnetic resonance angiography (MRA) would be per-
formed if a stenosis of> 30% is identified or in the pres-
ence of hypertension.
Ureteric abnormalities are of importance when select-
ing a kidney for transplant, as the ureters will typically
need to be anastomosed to the urinary bladder. A duplex
system is found in 0.7–3% of the adult population.25 Our
cohort displayed a 3.8% incidence (n = 6) of ureteric
abnormalities, complete duplex systems in 2 cases. Two
case in our cohort with partial duplex systems proceeded
to transplant.
© 2020 The Royal Australian and New Zealand College of Radiologists
Renal vascular anatomy in living renal donors
(b)
Potential living donors are assessed by a multidisci-
plinary team that includes nephrologists, transplant sur-
geons, immunologists, radiologists, social workers and
psychiatrists (if indicated). All donors are evaluated with
serological, urine and radiologic investigations. Many of
the investigations and clinical assessments are combined
to occur on a single day to reduce the number of visits
that a potential donor needs to make to the transplant
centre. Imaging modalities include chest radiography,
abdominal ultrasonography and radioisotope renography
to estimate glomerular filtration rate. Commonly MDCT is
performed on the same visit. Thus, if a potential donor
has been deemed unsuitable for reasons other than
anatomical reasons, such as medical and immunological
reasons, or due to subject decision not to proceed and/or
change in the health of the potential recipient, they may
have already undergone MDCT. 80 of our screened sub-
jects (50%) proceeded to donation.
The present study has several limitations. It is a sin-
gle-centre retrospective experience of potential donors
in a living-donor programme. Immediate and delayed
complications in recipients have not been analysed. Ini-
tially, this study was conceived as an assessment of
potential donors and therefore IRB approval had not
granted for evaluation of recipients. This would be a
relevant outcome measure for success in a living-donor
programme and should be the aim of further studies.
In conclusion, MDCT can identify the significant varia-
tion in renal arterial, venous and ureteric anatomy. This
information is crucial for the transplant surgeon.
Acknowledgements
The authors would like to acknowledge the assistance
of the transplant co-ordinator team in Beaumont Hospi-
tal. The study was discussed at out IRB board and
subsequently registered and approved (CA271). All
authors have approved the manuscript and consent for
publication. This study received no funding. Authors’
contributions are as follows: BM, EC, LT and DON col-
lected the data. DON, ML, RD and MM prepared the
manuscript. DON, DL and MM conceptualised and
designed the study. DON, MM, LT, BM and EC analysed
the data.
5
DC O’Neill et al.
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