The renal vasculature, consisting of the arteries and veins that supply and drain the kidneys, is a complex and vital network responsible for maintaining proper kidney function and, by extension, overall homeostasis within the human body. The kidneys in the retroperitoneal space are essential for filtering blood, regulating electrolytes, managing fluid balance, and eliminating metabolic waste. An adequate and consistent blood supply is paramount for these functions to occur efficiently [1]. Any deviations or variations in the standard anatomical configuration of the renal vasculature can have significant implications for renal physiology, medical imaging, and surgical intervention. Therefore, an in-depth understanding of the anatomical variations in the renal vasculature is crucial for healthcare professionals, particularly those involved in urology, nephrology, radiology, and vascular surgery [1]. The typical anatomy of the renal blood supply involves the renal arteries, which arise bilaterally from the abdominal aorta, usually at the level of the second lumbar vertebra. These arteries travel laterally toward the kidneys, entering the hilum (the central concave portion of the kidney) where they branch into segmental arteries, which in turn divide into smaller interlobar, arcuate, and interlobular arteries. The renal veins, tasked with draining deoxygenated blood from the kidneys, return this blood to the inferior vena cava. While this standard arrangement is commonly observed, it is not the rule for all individuals. Anatomical variations in renal arteries and veins, such as the presence of accessory arteries, multiple renal veins, or aberrant branching patterns, occur frequently. Several attempts to study the frequency of occurrence of renal vascular variations have been made, the first one from the Anatomical Society of Great Britain and Ireland in 1891 [1]. Studies have shown that these variations can be observed in a significant proportion of the population, with reports suggesting that as many as 30% of individuals may exhibit some form of renal vascular anomaly [2]. Anatomical deviations in the renal vasculature have profound clinical implications, particularly in the context of renal transplantation, nephrectomy, renal artery stenting, and other vascular procedures [3]. Moreover, the presence of variations in renal vasculature is also relevant in endovascular procedures such as angioplasty, stenting, or embolization [4].

Anomalies like multiple renal arteries or early branching of the renal artery may influence the approach taken during these interventions. Failing to account for such variations may lead to inadequate treatment, complications, or suboptimal outcomes. This is particularly crucial for patients with conditions like renal artery stenosis, where precise revascularization is required to restore blood flow and preserve renal function.

From an embryological perspective, renal vascular variations arise due to the complex developmental process that the kidneys and their blood supply undergo during fetal growth. The kidneys initially develop in the pelvic region and migrate superiorly during gestation, with their blood supply undergoing successive modifications. During this migration, multiple transient arteries arise from the aorta to supply the developing kidneys, some of which regress, while others persist, resulting in variations such as accessory renal arteries. Understanding this developmental process provides insight into why these variations are relatively common and highlights the necessity of considering them in clinical practice. The increasing use of advanced imaging modalities has greatly improved the ability to detect and characterize these anatomical variations. Techniques such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) allow for detailed visualization of the renal vasculature, offering three-dimensional reconstructions that aid in preoperative planning. Beyond their immediate clinical relevance, variations in the renal vasculature also have broader implications in medical education and research.

Anatomical studies of renal vasculature serve not only to enhance the knowledge base of medical professionals but also to contribute to the development of more sophisticated surgical techniques, improve patient outcomes, and guide innovations in medical device design, particularly in the field of endovascular interventions.

In this review, we will explore the various anatomical variations observed in renal vasculature, including accessory renal arteries, variations in renal venous anatomy, and aberrant branching patterns. We will also discuss their embryological origins, clinical significance, and implications for medical and surgical procedures. By synthesizing the available literature on renal vascular anomalies, we aim to provide a comprehensive understanding of how these variations affect clinical practice and patient care. The main objective of this review is to know the real prevalence of multiple renal arteries and veins in a wide, multiethnic population

In this review, we conducted an extensive literature search to investigate and document anatomical variations in renal vasculature. This process involved multiple stages, beginning with a thorough pre-analytical phase in which we identified a broad range of relevant scientific studies. We utilized several well-established and widely respected research databases, including Medline, Pub Med, Embase, Web of Science, and Google Scholar [5]. During the review, it was observed that several authors utilised well-established and widely accepted research databases including these databases which provided a solid foundation for our search, encompassing numerous peer-reviewed articles from diverse scientific fields. However, we recognized the need to expand our scope further to ensure a more comprehensive data collection. To this end, we also examined other prominent online libraries that host a wealth of scientific literature. These included the Scientific Electronic Library Online (SciELO), which offers open-access scientific journals from around the world, and Europe PubMed Central (Europe PMC), a significant repository of biomedical literature. Despite the comprehensive nature of these databases, the initial search yielded a relatively limited number of cases, particularly about the specific anatomical variations we were investigating. Consequently, we broadened our search to include specialized journals that focus on anatomy and morphology, ensuring a more targeted approach.

Our extended search included a variety of specialized journals, such as Scholar Science Journals, Hindawi Publishing Corporation, the International Journals in Medical and Health Research, and the International Journal of Experimental and Clinical Anatomy. We also explored regionally focused journals like the Romanian Journal of Morphology and Embryology, African Journals Online, Asian Pacific Journal of Health Sciences, and the Revista Argentina de Anatomia Clinica. In addition to these, we considered journals that focus on medical imaging and diagnostics, such as the American Journal of Roentgenology and journals from Via Medica and Impact Journals. This wide-reaching approach allowed us to gather studies from a diverse range of anatomical perspectives and geographical regions, enhancing the depth and breadth of our review.

The search was conducted without any time limitations, meaning that we reviewed studies published across a wide historical range, from older foundational studies to more recent contributions. This was crucial in capturing a comprehensive understanding of renal vascular variations, as historical studies often provide valuable anatomical insights. To ensure that we did not miss any relevant research, we used an extensive list of keywords, such as “renal artery branching pattern,” “renal vein variations,” “renal vascular anatomy,” “kidney arterial blood supply,” and “renal artery variations.”

Following the initial search, we identified 161 articles that appeared to meet our inclusion criteria. These articles were then subjected to a more rigorous selection process, where duplicates were removed, and studies with incomplete or insufficient data were excluded. After this refinement, 85 articles were retained for in-depth review and analysis. Each of these articles was carefully evaluated by the authors, who collectively reviewed the methodologies, results, and significance of the findings. These selected studies provided detailed data on the renal vasculature of 21,654 kidneys, encompassing a wide range of anatomical variations. This final collection of studies forms the core of the current review, providing a robust dataset for understanding the prevalence, types, and clinical significance of renal vascular variations. By synthesizing data from such a wide variety of sources, this review offers a comprehensive examination of renal vasculature, contributing valuable insights to the field of anatomy and providing a foundation for future clinical and surgical applications.

We reviewed eighty-one articles covering 21,654 kidneys. Multiple renal arteries (MRA) were identified in 4,439 kidneys, representing 20.49% of the total. The number of multiple renal arteries entering each kidney ranged from two to six [6-30].

The observations presented in Table 1 indicate that the majority of kidneys (89.32%) have two renal arteries, with the prevalence of kidneys possessing three renal arteries at 9.82%. The occurrence of kidneys with four, five, and six renal arteries is quite rare, accounting for only 0.72%, 0.09%, and 0.05%, respectively. Overall, the study highlights that a significant 20.49% of the total 21,654 kidneys examined have multiple renal arteries, indicating that a significant proportion of kidneys have variations in their arterial supply, with most showing two renal arteries. This information may be important for understanding variations in renal vascular anatomy, which could have clinical implications for surgical procedures and kidney transplantation.

Table 1: Showing the number of kidneys with multiple renal arteries and its prevalence

Only thirty-eight of the articles made the distinction between the right and left kidneys with multiple renal arteries. Among the 13160 kidneys analyzed in these studies, 2410 were found to have multiple renal arteries. Of these, 1180 (48.96%) were located in the right kidneys, while 1230 (51.04%) were in the left kidneys.

Table 2 shows that the majority of both right and left kidneys had two renal arteries, with 44.23% of right kidneys and 46.56% of left kidneys having two. The number of kidneys with three renal arteries was more common than those with four, five, or six, with only small differences between the right and left sides. Overall, the distribution of multiple renal arteries is almost equal between the two sides, although left kidneys have a slightly higher prevalence [31-42].

Table 2: Showing the prevalence of multiple renal arteries in right and left-sided kidneys

Early branching was identified in as few as twenty-two out of eighty-one articles, but no universal definition was established. Some articles defined early branching arbitrarily as a distance of 1.5 or 2 cm from the aorta to the division of the main renal artery in cases of multiple renal arteries, while others did not specify any limit. Among the 8,865 kidneys discussed in these articles, 1,063 (11.99%) exhibited early branching, regardless of the definitions used. Only a minority of the articles provided information on the lateralization of early branching: 376 (4.24%) were right kidneys, and 406 (4.58%) were left kidneys. In 281 (3.17%) of the cases, the right or left side was not specified in Table 3 [43-55].

Table 3: Showing the prevalence of early branching pattern of the renal arteries

The presence of accessory renal arteries has historically been associated with a theoretically higher risk of surgical complications for both living donors and recipients of renal grafts. This risk stems from the complex vascular anatomy and technical challenges inherent in managing such anatomical variations. In the past, the presence of accessory renal arteries was deemed a contraindication to renal transplantation, primarily due to concerns over surgical feasibility and potential complications. However, modern advancements in surgical techniques and a growing body of evidence have led to a paradigm shift. Most recent studies agree that multiple renal arteries no longer pose a significant barrier to successful transplantation, whether performed through open or laparoscopic nephrectomies [56-65].

Nonetheless, some clinicians and researchers continue to view the presence of accessory renal arteries as a contraindication to their use in transplantation. This perspective is often justified by the nature of accessory arteries as end-arteries, which necessitates their meticulous re-implantation. This process requires multiple anastomoses, which can significantly prolong ischemic time. The extended ischemic duration has been associated with an increased risk of post-transplant complications such as renal failure, graft rejection, reduced renographic clearance, and diminished graft function [66-70].

Beyond transplantation, accessory renal arteries also influence the management of other vascular conditions, such as endovascular repair of aortic aneurysms. Their presence and the extent of renal parenchyma perfused by these arteries can complicate treatment strategies. Mendes et al. [4] highlight the lack of consensus regarding the amount of renal parenchyma that can be safely sacrificed during endovascular procedures. While some authors, such as Satyapal et al. [5], have suggested that sacrificing an entire kidney may be justifiable in particularly challenging cases, Mendes et al. proposed more conservative exclusion criteria. In their fenestrated-branched device trials, open repair or alternative treatments were recommended when endovascular incorporation required the sacrifice of more than 40% of one kidney or 25% of both kidneys. Accessory renal arteries also play a role in renovascular hypertension, a form of secondary hypertension commonly caused by conditions such as atherosclerosis, fibromuscular dysplasia, or ureteropelvic junction obstruction. In some cases, the extrinsic compression of the ureteropelvic junction by an accessory renal artery is identified as the underlying cause [71-77]. Although rare, this condition is a surgically reversible cause of secondary hypertension that warrants investigation and treatment. A study by Verloop et al. [78] on resistant hypertension and arterial denervation revealed that 34% of patients had accessory renal arteries. Their findings suggest that renal denervation is an effective treatment for patients with multiple renal vessels, particularly when all arteries are amenable to treatment. Given the high prevalence of accessory renal arteries among patients with resistant hypertension, the study concluded that excluding such patients from this therapeutic option may not be justified.In oncologic conservative surgery, accessory renal arteries are pivotal in shaping surgical strategies. The incidence of renal tumors has risen steadily over the years, with many cases diagnosed at clinical stage T1. This stage often renders patients eligible for partial nephrectomy. With minimally invasive partial nephrectomy emerging as a viable alternative to open surgery, a comprehensive understanding of renal vascular anatomy is essential. Detailed preoperative planning and precise operative techniques are crucial to optimizing oncologic and functional outcomes [79].

Furthermore, inferior polar renal arteries have been implicated as a potential etiological factor in certain forms of hydronephrosis, which can often be surgically corrected [80]. These examples underscore the significant role of vascular anatomy in both common and rare medical conditions, as well as its critical influence on surgical planning and patient outcomes. Finally, it is essential to emphasize the value of a universally accepted medical nomenclature. Such standardization enables faster, more accurate communication of clinical findings and surgical outcomes, facilitating the development of comprehensive research databases rooted in objective anatomical descriptions. This shared language is indispensable for advancing clinical practice and research in the ever-evolving field of medicine.

Our research highlights the prevalence and clinical significance of anatomical variations in renal arteries. Approximately 20% of the population presents with multiple renal arteries, with double renal arteries being the most frequently observed variant. Despite the relatively high prevalence of these variations, lateralization of multiple renal arteries has been documented in only a minority of studies, and no significant side predilection was noted.

Furthermore, early branching patterns, described in just 22 articles, were observed in 11.99% of kidneys, distributed as 4.24% on the right side, 4.58% on the left side, and 3.17% without side specification.

These anatomical variations have far-reaching implications across multiple medical specialties, including nephrology, urology, oncology, and vascular surgery. The presence of multiple renal arteries or early branching patterns can complicate procedures such as nephrectomies, renal transplantations, endovascular interventions, and oncologic surgeries. A detailed understanding of these variations is critical for preoperative planning and intraoperative decision-making, as it can help minimize complications, optimize outcomes, and tailor treatments to individual patients.

To our knowledge, this study represents the most comprehensive anatomical review of renal artery variations, encompassing data from a diverse and extensive population. Our findings underscore the necessity for clinicians to remain vigilant about these anatomical variations in both routine clinical assessments and specialized surgical procedures. Incorporating knowledge of such vascular anomalies into clinical practice can significantly enhance patient care, reduce surgical risks, and improve therapeutic outcomes. This work serves as a vital reference for future studies and a foundation for developing more effective strategies to address the challenges posed by renal artery variations in clinical and surgical contexts.

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