*Purpose: Peripheral arterial disease (PAD) that needs treatment is common and major complication in patients with chronic kidney disease (CKD). Most surgeons have been using iliac artery for kidney transplantation, but there is little data of long-term effect of kidney transplantation (KT) on PAD among the recipients with CKD.

*Methods: Cohort data were collected retrospectively and analyzed with continuing data accumulation from 2005 to 2012. More recent data was excluded for long-term follow-up result over 5 years, and only patients over 40 years were included, because younger patients used to have vasculitis or vascular complications from congenital malformations. If graft artery was anastomosed to internal iliac artery, that was excluded for more definite effect to lower extremity arteries. Only the first surgery was included to analysis per one patient. Area of recipient arterial wall and lumen were measured geometrically, and arterial calcification was calculated by Hounsfield units per unit area using computed tomography images.

*Results: Totally, 240 recipients were suitable for analysis, 209 patients received new kidney anastomosed to their common iliac artery (CIA), 118 patients to their external iliac artery (EIA). Every CIA was larger cross-sectional and lumen area, but more stenosis rate, wall thickness area, and wall calcification than EIA. There were 13 surgeries include bypass, amputation, and endovascular intervention for ipsilateral leg arteries and 9 surgeries for contralateral leg arteries in 15 patients after KT. In 6 patients, the surgery was performed on their ipsilateral leg only (6 EIA), although their contralateral EIA that was not received surgery had more stenosis rate, larger wall thickness area, higher wall calcification score. In 2 patients, they received the surgery on their contralateral leg only (1 CIA, 1 EIA), their wall calcification score was higher in the contralateral leg. In multivariate analysis, the variables that associated with ipsilateral surgery were female sex, less luminal area of anastomosed recipient artery, EIA anastomosis (than CIA), large total cross-sectional area of CIA (include wall and lumen, irrespective of anastomosis site).

*Conclusions: Kidney transplantation would have potential adverse effect on PAD. Prospective study including long-term follow-up with objective vascular test like ankle-brachial index or walking impairment questionnaire are needed, especially for the old, diabetic, or the recipients with chronic limb ischemia after the KT.

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