Background. Live donor kidneys with multiple arteries are associated with surgical complexity for removal and increased rate of recipient ureteral complications. We evaluated the outcome of vascular imaging and the clinical consequences of multiple arteries and veins. Methods. From 2001 to 2005 data of 288 live kidney donations and transplantations were prospectively collected. Vascular anatomy at operation was compared with vascular anatomy as imaged by magnetic resonance imaging (MRI) or subtraction angiography, and consequences of multiple vessels were investigated. Results. Simple renal anatomy with a solitary artery and vein was present in 208 (72%) kidneys. Sixty (21%) transplants had multiple arteries. Thirty (10%) transplants had multiple veins. Magnetic resonance imaging failed to predict arterial anatomy in 23 of 220 donors (10%) compared with 3 of 101 (3%) after angiography. The presence of multiple veins did not influence outcomes after nephrectomy in general. Multiple arteries did not affect clinical outcomes in open donor nephrectomy (n = 103). In laparoscopic donor nephrectomy (n = 185) multiple arteries were associated with longer operation times (245vs. 221 min, P=0.023) and increased blood loss (225 vs. 220mL, P=0.029). In general, neither multiple arteries nor vascular reconstructions influenced recipient creatinine clearance or ureteral complication rate. However, accessory arteries to the lower pole correlated with an increased rate of ureteral complications (47% vs. 14%, P=0.01). Conclusions. Multiple arteries may increase operation time. Accessory lower pole arteries are associated with a higher rate of recipient ureteral complications indicating the importance of arterial imaging. Currently, both magnetic resonance imaging and angiography provide suboptimal information on renal vascular anatomy.