Left out and alone: selection bias in kidney transplantation

Living donor nephrectomy has represented the majority of kidney transplantation cases since the emergence of laparoscopy in the early 1990s. Despite drastic improvements in technology, pharmacology, and surgical outcomes for both recipient and donor, practice prefers left kidney harvest over right. This decision reflects an anatomical preference established in the cadaver donor population that is now applied to the living in explicit guidelines by the United Organ Sharing Network (UNOS). While there is a strong consensus to leave the stronger kidney for the donor, surgical practice still maintains the opposite: harvesting the left for a more expedient procedure for the surgeon, donor, and recipient. However, data collected by UNOS reflects a different story than the guidelines suggest: that the faster and safer procedure for the recipient and donor is actually the right nephrectomy. This choice suggests that ritual is dictating clinical decisions and not results. As UNOS is the main data collection agency, as well as the waiting list manager, organ procurer, and guideline publisher, there is a closed data loop, with historical preference remaining unchanged and unchallenged. Additionally, the absence of investigations within the donor population to understand health outcomes as a result of this selection bias, or the procedure in general, is concerning and must be addressed.