Expanding boundaries: The evolution and future of living donor kidney transplantation

Table 1 Core components of Enhanced Recovery After Surgery protocols in living donor kidney transplantation

Enhanced Recovery After Surgery domain	Intervention strategies	Intended benefit
Preoperative	Patient education, prehabilitation, carbohydrate loading	Reduce anxiety, enhance metabolic readiness
Intraoperative	Opioid-sparing anesthesia, goal-directed fluid therapy, normothermia	Minimize physiologic stress, maintain stability
Postoperative	Early mobilization, multimodal analgesia, early oral intake	Shorten recovery, reduce complications
Discharge planning	Standardized criteria for discharge, coordinated outpatient follow-up	Reduce length of stay, improve continuity of care

Table 2 Comparative surgical and anatomical considerations in right vs left nephrectomy in living donor kidney transplantation

Transplant-relevant parameter	Left donor nephrectomy	Right donor nephrectomy
Renal vein anatomy	Longer renal vein, which facilitates easier venous anastomosis during graft implantation	Shorter renal vein, which increases technical complexity during vascular anastomosis
Surgical accessibility	Standard approach in most centers	Requires higher surgical expertise in select cases
Implantation challenges	Fewer technical modifications required	May require vascular extension or reconstruction
Risk of vascular complications	Lower (fewer IVC-related concerns)	Higher risk of IVC injury, venous thrombosis
Warm ischemia and handling time	Slightly longer due to more frequent laparoscopic use	May be shorter in open approaches
Utilization in practice	Approximately 80%-85% of living donor kidney transplantation cases	Approximately 15%-20%, used when left kidney is not suitable
Reported graft outcomes	Lower risk of DGF and early graft loss	Slightly higher risk of DGF and early graft loss
Preferred in vascular anomalies	More versatile with multiple arteries/veins	Occasionally favored with specific anatomical variants

DGF: Delayed graft function; IVC: Inferior vena cava.