Upside-down kidney placement: An alternative in pediatric renal transplantation

Published:September 29, 2020DOI:



      “Upside-down” kidney placement has been reported as an acceptable alternative in cases of technical difficulty in kidney transplantation but there are few reports in the pediatric population.
      The aim of our study is to analyze whether the placement of the upside-down kidney could affect graft outcome or produce more complications.

      Materials and methods

      A retrospective study was conducted of pediatric kidney transplants performed in our center between 2005 and 2017 with at least 6 months' follow-up.
      Epidemiological and anthropometric data, type of donor (deceased/living), graft position (normal/upside-down), reason for the upside-down placement, early, medium and long-term complications and renal function were analyzed and compared with patients transplanted in the same period with a normal graft placement.


      From 181 transplants, 167 grafts were placed in a normal position (mean age: 10 y and mean weight: 30 kg) and 14 were placed upside-down (10 y, 37 kg) mainly because of vessel shortness after laparoscopic nephrectomy. Male predominance was observed in both groups.
      57% of grafts from the control group and 64% of those from study group came from a living donor.
      Four vascular and two ureteral re-anastomoses were recorded in the control group and two vascular and one ureteral re-anastomosis in the study group (p > 0.05). In the latter group, no grafts have been lost due to vascular or urological causes and no patients have required dialysis.


      When necessary, an upside-down placement for the renal graft is a safe alternative in the pediatric population.

      Level of evidence

      Level III.


      Renal transplantation (RT), End-stage renal disease (ESRD)

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Najarian J.S.
        • Almond P.S.
        • Mauer M.
        • et al.
        Renal transplantation in the first year of life: the treatment of choice for infants with end-stage renal disease.
        J Am Soc Nephrol. 1992; 2: S228-S233
        • Starzl T.E.
        • Marchioro T.L.
        • Porter K.A.
        • et al.
        The role of organ transplantation in pediatrics.
        Pediatr Clin N Am. 1966; 13: 381-422
        • Sharma A.
        • Ramanathan R.
        • Behnke M.
        • et al.
        Single pediatric kidney transplantation in adult recipients: comparable outcomes with standard-criteria deceased-donor kidney transplantation.
        Transplantation. 2013; 95: 1354-1359
        • Ishitani M.
        • Isaacs R.
        • Norwood V.
        • et al.
        Predictors of graft survival in pediatric living-related kidney transplant recipients.
        Transplantation. 2000; 70: 288-292
        • Cho M.H.
        Pediatric kidney transplantation is different from adult kidney transplantation [published correction appears in Korean J Pediatr. 2018 Aug;61(8):264].
        Korean J Pediatr. 2018; 61: 205-209
        • Amesty M.V.
        • Fernandez C.
        • Espinosa L.
        • et al.
        Long-term outcomes of adult-size and size-matched kidney transplants in small pediatric recipients.
        J Pediatr Urol. 2020; ([published online ahead of print, 2020 May 20]) (S1477–5131(20)30180–7)
        • Goldsmith P.J.
        • Asthana S.
        • Fitzpatrick M.
        • et al.
        Transplantation of adult-sized kidneys in low-weight pediatric recipients achieves short-term outcomes comparable to size-matched grafts.
        Pediatr Transplant. 2010; 14: 919-924
        • Ballesteros Sampol J.J.
        • Guzmán Fernández A.
        • Cortadellas Angel R.
        Es la posición invertida del injerto renal causa de patología tras el trasplante? [is the inverted position of the kidney graft a cause of disease after transplantation?].
        Actas Urol Esp. 1994; 18: 723-727
        • Ratner L.E.
        • Ciseck L.J.
        • Moore R.G.
        • et al.
        Laparoscopic live donor nephrectomy.
        Transplantation. 1995; 60: 1047-1049
        • Simforoosh N.
        • Aminsharifi A.
        • Tabibi A.
        • et al.
        Right laparoscopic donor nephrectomy and the use of inverted kidney transplantation: an alternative technique.
        BJU Int. 2007; 100: 1347-1350
        • Troppmann C.
        • Pierce J.L.
        • Wiesmann K.M.
        • et al.
        Early and late recipient graft function and donor outcome after laparoscopic vs open adult live donor nephrectomy for pediatric renal transplantation.
        Arch Surg. 2002; 137: 908-916
        • Alcocer F.
        • Zazueta E.
        Montes de Oca J. the superficial femoral vein: a valuable conduit for a short renal vein in kidney transplantation.
        Transplant Proc. 2009; 41: 1963-1965
        • Sener A.
        • Cooper M.
        Live donor nephrectomy for kidney transplantation.
        Nat Clin Pract Urol. 2008; 5: 203-210
        • El-Galley R.
        • Hood N.
        • Young C.J.
        • et al.
        Donor nephrectomy: a comparison of techniques and results of open, hand assisted and full laparoscopic nephrectomy.
        J Urol. 2004; 171: 40-43
        • Hamburger J.
        • Crosnier J.
        • Dormont J.
        • et al.
        Renal transplantation theory and practice.
        Williams & Wilkins Co., Baltimore1972
        • Ramesh S.
        • Taylor K.
        • Koyle M.A.
        • et al.
        "Inverted" positioning of renal allograft during kidney transplantation in children and adolescents: A single-institution comparative analysis.
        Pediatr Transplant. 2019; 23: e13365