Resistance Index Measured by Doppler Ultrasound as a Predictor of

Graft Function After Kidney Transplantation

H. Canoa,*, D.A. Castañedaa, N. Patiñoa, H.C. Péreza, M. Sáncheza, E. Lozanob, and M.C. Pérezc
a
Organ and Tissues Transplant Group, School of Medicine at the National University of Colombia, Bogotá, Columbia; bOrgan and
Tissues Transplant Group Chief, Kidney Transplant Surgeron at San Ignacio Hospital, Bogotá, Colombia; and cRadiologist, Fundación
Cardio Infantil, Bogotá, Colombia

ABSTRACT
Introduction. Doppler ultrasound (US) has become the primary imaging technique for
the evaluation of renal transplants. It provides information about the intrarenal resistance
index (RI). A high RI is seen in every form of graft dysfunction. In this article, we review
the utility of sonography, particularly the intrarenal RI measured early after renal trans-
plant, as a predictor of acute and chronic clinical outcome in patients.
Results. RI is a valuable marker to determine graft function and related vascular com-
plications. It reveals a strong correlation with serum creatinine levels measured days after
transplant. Its elevation is typical for acute tubular necrosis and can be used to predict its
duration. An RI >1 (absent end-diastolic flow) seen in the first weeks after transplant is
associated with impaired renal graft recovery. In addition, it is an early predictor of
chronic allograft nephropathy (even correlated with biopsy results), which will allow a
change in therapy.
Conclusions. RI measured serially in the early period after kidney transplantation is a
valuable marker for determining renal graft function. It is also useful for demonstrating
various types of graft dysfunction; however, it cannot differentiate between them. In recent
studies, extrarenal factors in kidney transplantation (eg, recipient’s age) may significantly
influence RI in the recipient, demonstrating that RI depends on the vascular characteristics
of the recipient and not on the graft itself.

K IDNEY transplantation is considered the treatment of

choice for end-stage renal disease. Over the past few
decades, gray-scale sonography in combination with spectral
and color Doppler has revolutionized the practice of
nephrology. Sonography has become the primary imaging
technique for the evaluation of renal transplants; it is an
inexpensive, noninvasive, non-nephrotoxic, simple, and
readily available imaging method for evaluating a kidney
transplant that allows rapid diagnosis of complications that
endanger graft viability. A baseline Doppler examination is
performed shortly after surgery, and follow-up examinations
are then performed as needed based on the patient’s clinical
status [1e17].
In the present article, we reviewed the utility of sonog-
raphy, particularly the intrarenal resistance index (RI)
measured early after renal transplant, as a predictor of acute
and chronic clinical outcome in patients.
MATERIALS AND METHODS
The Medline and Embase databases were searched. The Medical
Subject Heading terms used were: “kidney transplantation,” “ul-
trasonography,” and “kidney transplantation/ultrasonography.” The
search was limited to clinical trials, randomized controlled trials,
and reviews in the past 10 years. Abstracts of retrieved citations
were reviewed and prioritized according to relevance. Full articles
were obtained, and reference lists were reviewed for additional
articles when appropriate.
DOPPLER EXAMINATION
The spectral parameters most commonly assessed by
Doppler ultrasound include peak systolic velocity,
*Address correspondence to Hernan Dario Cano Riano, MD,
Ruitoque Condominio, El Laguito, Cabaña 11, Floridablanca,
Santander, Colombia. E-mail: hernancano123@gmail.com

0041-1345/14 ª 2014 by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.transproceed.2014.07.001 360 Park Avenue South, New York, NY 10010-1710

2972 Transplantation Proceedings, 46, 2972e2974 (2014)

RESISTANCE INDEX AS A PREDICTOR OF GRAFT FUNCTION AFTER KIDNEY TRANSPLANT
acceleration time, and RI. Additional parameters that may
also be assessed include pulsatility index (PI) and iliac artery
to transplant artery peak systolic velocity ratios [1]. The
normal renal artery displays forward systolic and diastolic
flow due to low distal vascular resistance; the normal
intrarenal arterial waveform is one of low resistance,
thereby maintaining high perfusion of the kidney [2]. RI is
the ratio of the systolicediastolic difference divided by the
systolic velocity. RI is considered to be normal if it is <0.7,
indeterminate between 0.7 and 0.8, and elevated if >0.8 [3].
When RI equals 1, there is decreased diastolic velocity
corresponding to absent end-diastolic flow [2,3].
The spectral Doppler examination may show an elevated
RI in all forms of graft dysfunction [4e7]. The elevated RI
results from various causes of interstitial edema [4,5,8],
which is most reflected in the diastolic phase of the arterial
waveform [2,4,5,7,8]. Serial measurements of RI may be
helpful to determine if the insult is worsening and to
monitor therapeutic interventions [4,7,8]. Although RIs
cannot differentiate among the causes of early graft
dysfunction [2,4e7], a normal RI in the immediate trans-
plant period is a good predictor of immediate graft function
[4e7] (Fig 1).
RESULTS
The lowest RI values (0.72) were observed among patients
with immediate graft function; moderate values (0.78)
occurred in those with slow graft function; and the highest
values (0.83) occurred in those with delayed graft function
(these differences were highly significant). Ischemic injury,
which occurred mainly before organ harvesting, played a
dominant role in determining intrarenal resistance in the
early posttransplant period [4]. These same authors in 2009
2973
found that the discontinuous spectrum of flow in the
segmental arteries of the kidney graft in the early period
after kidney transplantation is typical for acute tubular
necrosis and predicts its duration [6]. Finally, in 2013,
analyzing extrarenal factors that influence RI in kidney
transplantation, they concluded that arterial stiffness and
left ventricular hypertrophy in the recipient may signifi-
cantly influence the intrarenal vascular resistance [9]. They
found the strongest correlation with high RI was age in the
recipient, not in the donor, confirming that RI depends on
the vascular characteristics of the recipient and not on the
graft itself [9,10].
In the spectrum of elevated RI, an elevation 1 is known
as absent end-diastolic flow; when this condition is observed
within the first week after transplantation, it is associated
with impaired renal functional recovery [3]. This outcome
confirms that the higher the RI, the worst the prognosis.
RI is sometimes used together with PI to help in the
evaluation of the graft. RI and PI are valuable Doppler
ultrasonography markers for determining the kidney allo-
graft function and the related vascular complications [11].
Some studies correlate PI and RI with creatinine elevation
early after kidney transplantation and reveal a strong to
medium correlation between RI and PI and serum creati-
nine levels measured 6 days after transplant [12]. RI and PI
are also effective means of diagnosing posttransplant renal
complications. Including a serial assessment and considering
the maximum values of RI could improve the diagnostic
efficacy on day 5 after transplant [13].
RI is also a helpful tool in evaluating the prognosis of
graft viability in the chronic period after transplant. An
elevated RI is an early predictor of histologically (correlated
with biopsy results) relevant chronic allograft nephropathy;
early evidence of chronic allograft nephropathy may allow
Fig 1. Normal resistance index measured
by using Doppler ultrasound in a 26-year-
old posttransplant patient. Image provided
by M.C. Pérez, MD, Radiologist, Fundación
Cardioinfantil, Bogotá, Colombia.
2974
for a targeted change in therapy before clinically significant
injury occurs [14]. PI and RI in the early posttransplantation
period correlate with long-term transplant function and can
potentially be used as prognostic markers to aid risk strati-
fication for future transplant dysfunction [15]. A high RI
value measured intraoperatively has been shown to be a
valuable predictor of early and long-term kidney graft
function [16]. RI measured 12 to 18 months after trans-
plantation seems useful for predicting long-term allograft
outcomes [17].
CONCLUSION
The majority of authors agree that RI measured serially in
the early period after kidney transplantation is a valuable
marker for determining renal graft function. It is also useful
for demonstrating various types of graft dysfunction such as
acute rejection, calcineurin inhibitor toxicity, acute tubular
necrosis, renal vein thrombosis, ureteral obstruction, and
pyelonephritis. However, it cannot differentiate between
these factors. In addition, RI in the chronic period is a
predictor of early chronic allograft nephropathy (even
correlated with biopsy results). In recent studies, extrarenal
factors in kidney transplantation (eg, arterial stiffness, left
ventricular hypertrophy, age of the recipient) may signifi-
cantly influence RI in the recipient, showing that RI de-
pends on the vascular characteristics of the recipient and
not on the graft itself.
REFERENCES
[1] Li J, Ji Z, Cai S, et al. Evaluation of severe transplant renal
artery stenosis with Doppler sonography. J Clin Ultrasound
2005;33:261e9.
[2] Friedewald SM, Molmenti EP, Friedewald JJ, et al. Vascular
and nonvascular complications of renal transplants: sonographic
evaluation and correlation with other imaging modalities, surgery
and pathology. J Clin Ultrasound 2005;33:127e39.
[3] Ba S, Halimi JM, Al-Najjar A, Barbet C, Buchler M,
Brunereau L, et al. Prognostic value of absent end-diastolic flow
within the first week following renal transplantation. Transplant
Proc 2009;41:645e7.
[4] Chudek J, Kolonko A, Krol R, et al. The intrarenal resistance
parameters measured by duplex Doppler ultrasound shortly after
CANO, CASTAÑEDA, PATIÑO ET AL
kidney transplantation in patients with immediate, slow and delayed
graft function. Transplant Proc 2006;38:42e5.
[5] Datta R, Sandhu M, Saxena AK, et al. Role of duplex
Doppler and power Doppler sonography in transplanted kidneys
with acute renal parenchymal dysfunction. Australas Radiol
2005;49:15e20.
[6] Kolonko A, Chudek J, Wicek A. Prediction of the severity
and outcome of acute tubular necrosis based on continuity of
Doppler spectrum in the early period after kidney transplantation.
Nephrol Dial Transplant 2009;24:1631e5.
[7] Hollenbeck M, Hilbert N, Meusel F, Grabensee B. Increasing
sensitivity and specificity of Doppler sonographic detection of renal
transplant rejection with serial investigative technique. Clin Investig
1994;72:609e15.
[8] Hillburn MD, Bude RO, Murphy KJ, et al. Renal transplant
evaluation with power Doppler ultrasound. Br J Radiol 1997;70:
39e42.
[9] Kolonko A, Szotowska M, Kuczera P, Chudek J, Wiecek A.
Extra renal factors influencing resistance index in stable kidney
transplant recipients. Transplantation 2013;96:406e12.
[10] Naesens M, Heylen L, Lerut E, et al. Intrarenal resistive
index after renal transplantation. N Engl J Med 2013;369:
1797e806.
[11] Nezami N, Kazem Tarzamni M, Argani H, Nourifar M.
Doppler ultrasonographic indexes in kidney transplant recipients:
its relationship with kidney function. Iran J Kidney Dis 2007;1:82e7.
[12] Ghorbani A, Shirazi AS, Sametzadeh M, Mansoori P,
Taheri A. Relation of resistive and pulsatility indices with graft
function after renal transplant. Exp Clin Transplant 2012;10:
568e72.
[13] Radmehr A, Jandaghi AB, Hashemi Taheri AP, Shakiba M.
Serial resistive index and pulsatility index for diagnosing renal
complications in the early posttransplant phase: improving diag-
nostic efficacy by considering maximum values. Exp Clin Transplant
2008;6:161e7.
[14] Elster EA, Hale DA, Mannon RB, Cendales LC, et al.
Surgical transplant physical examination: correlation of renal
resistance index and biopsy-proven chronic allograft nephropathy.
J Am Coll Surg 2005;200:552e6.
[15] McArthur C, Geddes CC, Baxter GM. Early measurement
of pulsatility and resistive indexes: correlation with long-term renal
transplant function. Radiology 2011;259:278e85.
[16] Król R, Chudek J, Kolonko A, Ziaja J, Pawlicki J,
Wiecek A, Cierpka L. Intraoperative resistance index measured
with transonic flow meter on kidney graft artery can predict early
and long-term graft function. Transplant Proc 2011;43:2926e9.
[17] Kramann R, Frank D, Brandenburg VM, Heussen N,
Takahama J, Krüger T, et al. Prognostic impact of renal arterial
resistance index upon renal allograft survival: the time point mat-
ters. Nephrol Dial Transplant 2012;27:3958e63.