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Nephrectomy in pediatric kidney transplantation is still practiced routinely at some institutions. Despite this, the clinical utility of nephrectomy for certain indications such as proteinuria and hypertension on pre- and post-transplant outcomes is unknown.

All children who underwent kidney transplant and native nephrectomy between 2009 and 2025 were reviewed for baseline clinical covariates, operative details, and outcomes.

Of the study population, 70 patients underwent unilateral nephrectomy and 61 underwent bilateral nephrectomy. The median age at transplant in the unilateral nephrectomy group was 12.5 years [9.3, 15.9] vs. 10.7 [7.1, 14.1] in the bilateral nephrectomy group. Operative time was 351.5 [294.8, 413.8] minutes vs. 353 [292, 420], median hospital length of stay 8 days [7, 11] vs. 11 days [8, 16], complications 8 (11%) vs. 15 (25%), and post-transplant delayed graft function 4 patients (6%) vs. 7 (12%). Rejection occurred in 1 patient per group. In the 18 patients who had a nephrectomy for proteinuria, the change in albumin was similar between groups (0.4 g/dL [-0.1, 0.4] vs. 0 g/dL [-0.2, 0.2]). In the 23 patients who had a nephrectomy for hypertension, the change in antihypertensive medications after transplant was higher in the unilateral nephrectomy group (1.5 medications less [0.8, 2] vs. 0 [0, 1]).

For the indications of proteinuria and hypertension, clinical outcomes were similar between bilateral vs. unilateral nephrectomy for individuals who underwent kidney transplantation. These findings support consideration of pursuing fewer bilateral native nephrectomies in these patient populations.