*Purpose: Variations in kidney anatomy, such as the presence of multiple arteries, may affect decisions regarding implantation. A significant proportion of living donor and some deceased donor kidneys with multiple arteries require multiple anastomoses or reconstruction. We aimed to assess the effect of multiple arteries on kidney transplant outcomes.

*Methods: We performed a registry analysis of all transplants in the UK from 2008-2018. Living donor (LD) and deceased donor (DD) kidney transplants were assessed separately. Univariate and multivariate analyses were performed to assess the effect of multiple arteries on graft outcomes including 3, 12, and 60 month graft function and the incidence of DGF and vascular thrombosis causing graft failure.

*Results: 13240 living donors and 28095 deceased donors were analysed. Warm ischaemic times in single artery kidneys was lower than kidneys with multiple arteries (LD 42 vs 45mins, p=0.025, DD 40 vs 43mins, p<0.001). Donor characteristics, terminal creatinine, were similar between both groups. In multivariate analysis adjusted for age, sex, diabetes, cold ischaemic time, and warm ischaemic time, there was no difference in mean creatinine at 3, 12 or 60 months in LD and DD with single or multiple arteries. There was an increased incidence in vascular thrombosis seen in LD with multiple arteries (2.2% vs 4.5%, p=0.008), but not in deceased donors (3.7% vs 4.0%, p=0.584). There was no difference in the incidence of DGF or PNF. In LDs, multiple arteries had no effect on transplant survival time (p=0.473), but DDs with multiple arteries had poorer survival (mean survival 5493 vs 5649 days, p=0.007).

*Conclusions: While multiple arteries may pose technical challenges and there is a prolonged warm ischaemic time, the long term clinical implications of this are minimal. The increased risk of graft thrombosis in LDs is clinically relevant but their long term graft survival and graft outcomes remain excellent

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