Critical review of the article on ‘Investigation of Predictive Factors for Function of Transplanted Kidney Graft Based on Zero-Time Biopsy Findings’

Citation: Miri, M. M., Ramezani-Binabaj, M., Inanloo, S. H., Barzegar Bafrouei, M., Sefidbakht, S., & Yahyazadeh, S. R. (2023). Investigation of Predictive Factors for Function of Transplanted Kidney Graft Based on Zero-Time Biopsy Findings. Translational Research in Urology, 5(3), 121-127. doi: 10.22034/tru.2023.407821.1154


The main aim of investigators in this study was to identify predictive histological findings of deceased donor kidney transplant outcome. Thirty-seven recipients from 2018-2021in Iran have been included in this study. Just after the ligation of blood vessels a wedge-shaped renal tissue sample has been taken for evaluation. Microscopic level abnormalities were categorized according to the standard scoring using Banff scoring system and kidney functions were monitored for a period of one year. Most commonly reported results were likely secondary to reduced perfusion of the kidney. According to the results, nearly nineteen percent of patients took longer time than expected to recover their kidney functions. Interestingly, there were microscopic level permeant abnormalities in those patients’ kidneys. Also, the kidney functions were inferior to the other group. However, it was not statistically significant. Older age, Diabetes and other comorbidities did not show any significant associations with recovery. Finally, no statistically significant relationship was found between the histopathological findings and short-term (6 months) graft function.


KT is the best treatment for renal failure. Credit is due to the investigators for their commendable effort in conducting this study, which aims to identify the risk factors associated with graft loss and suboptimal transplantation outcomes. According to a study conducted by Luyckx and team in 2018, zero-time biopsy represent the healthiness of the donated kidney [1] and these findings can be useful in evaluating the outcome of the transplanted kidney. Because, it provides an objective window on the state of the organ quality that cannot be deduced from clinical records and other renal function tests as per study conducted by Goumenos in 2010 [2]. The quality of a deceased donor kidney can be influenced by donor illnesses, transportation delays, perfusion issues, and the implantation process to a greater extent than a kidney from a live donor. Therefore, assessing the quality prior to kidney transplant surgery is very important.

It is inappropriate to draw conclusions on short-term graft function based on statistically insignificant relationships with histopathological findings. However, there are previous studies with similar results. Dare and the team reported that, histological changes as the most associated with poor graft outcomes [3]. Another study from Spain reported that, donor biopsies as normal in 74 per cent of cases and chronic renal lesions in 25.9% of cases [4].

According to the methods of sample collection of this study, they obtained it as wedge biopsy just after the completion of vascular anastomosis. Since, anastomosis time independently increased the kidney recovery time and the function after transplantation according to another study conducted by Heylen [5], it is better if they can obtain the biopsy sample before the vascular anastomosis. Other than that, obtaining a wedge biopsy before vascular anastomosis (connection of blood vessels between the donor kidney and recipient) allows for an assessment of the organ’s health and function before it is fully integrated into the recipient’s circulation. This can provide important information about the donor kidney’s viability and help identify any pre-existing issues that might affect its function.

Complications which occur in post- KT period can be categorized as; early (within the first 30 days of transplant), and late complications. Kidney transplant recipients often face a lot of challenges during the initial months post-surgery, such as adapting to immunosuppressive medications, managing potential complications, and stabilizing graft function. When considering the follow-up period of this study, it ended up 6 month (short term) post-KT period. But according to the previous literature, most of the studies followed up at least 1-year post-KT period. Since, we can assess short term outcomes within 6 months, it is important follow-up clinically adequate period when treating this type of complex medical condition. Because, immunological and non-immunological factors directly affect for the graft outcomes as well as the donor organ quality.


This critique acknowledges the significance of zero-time biopsy in evaluating transplant prognosis, emphasizing the need to assess the quality of deceased donor kidneys before transplantation. However, it suggests a methodological improvement by obtaining biopsy samples before vascular anastomosis, potentially offering a more accurate assessment of the organ’s viability. And, also highlights the short-term focus of the study (6 months post-KT) compared to the more common 1-year follow-up in transplant studies. It emphasizes the complexity of kidney transplant recipients’ challenges in the initial months post-surgery, suggesting a more extended follow-up to capture both early and late complications.

While the study contributes valuable insights into histopathological findings and short-term transplant outcomes, it faces limitations such as the short follow-up period and the need for a larger sample size. The critique underscores the importance of considering both immunological and non-immunological factors, suggesting that future studies should incorporate a more extended follow-up period and potentially refine the biopsy sample collection method. Overall, this study initiates a crucial exploration but invites further refinement and expansion to enhance its clinical relevance and applicability in KT.


[1]      V. A. Luyckx, M. Tonelli, and J. W. Stanifer, “The global burden of kidney disease and the sustainable development goals,” Bull World Health Organ, vol. 96, no. 6, p. 414, Jun. 2018, doi: 10.2471/BLT.17.206441.

[2]      D. S. Goumenos et al., “The prognostic value of frozen section preimplantation graft biopsy in the outcome of renal transplantation,” Ren Fail, vol. 32, no. 4, pp. 434–439, May 2010, doi: 10.3109/08860221003658241.

[3]      A. J. Dare, G. J. Pettigrew, and K. Saeb-Parsy, “Preoperative assessment of the deceased-donor kidney: from macroscopic appearance to molecular biomarkers,” Transplantation, vol. 97, no. 8, pp. 797–807, Apr. 2014, doi: 10.1097/01.TP.0000441361.34103.53.

[4]      J. A. Lopes et al., “Evaluation of pre-implantation kidney biopsies: Comparison of Banff criteria to a morphometric approach,” Kidney Int, vol. 67, no. 4, pp. 1595–1600, Apr. 2005, doi: 10.1111/J.1523-1755.2005.00241.X.

[5]      L. Heylen et al., “The Effect of Anastomosis Time on Outcome in Recipients of Kidneys Donated After Brain Death: A Cohort Study,” American Journal of Transplantation, vol. 15, no. 11, pp. 2900–2907, Nov. 2015, doi: 10.1111/AJT.13397.


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