Association between Early Resistive Index Measurement and Early Graft Function and Long-Term Graft Survival after Kidney Transplantation: an Evidence-based Clinical Review

Pande Made Wisnu Tirtayasa, Gede Wirya Kusuma Duarsa, Gerhard Reinaldi Situmorang, I Wayan Yudiana, Kadek Budi Santosa, Anak Agung Gde Oka, Arry Rodjani, Nur Rasyid


Background: resistive index (RI) is highly utilised to assess the graft function using Doppler ultrasonography. The RI has been shown as the best ultrasound parameter to assess kidney allograft dysfunction. Several studies have established the role of the RI as a predictor of transplant failure. However, these studies were using RI measurement in the later stages post transplantation. The present study has conducted to identify the association between early RI measurement and early graft function represented as delayed graft function (DGF) and immediate graft function (IGF), as well as long-term graft survival. Methods: an evidence-based clinical review of studies published before May 2018 was conducted from Medline, Science Direct, EMBASE and Cochrane databases. Studies on early measurement of RI whereby the primary or secondary goals of the study related to graft function and/or graft survival were included. Studies using late RI measurement and without RI value groups were excluded. The Mantzel-Haenzel method was used to analyse pooled risk ratio and 95% confidence interval, while the heterogeneity of the study was calculated through I2 value. Data analysis was performed using Review Manager 5.3. Results: nine studies with a total of 1802 patients who had undergone a kidney transplant were analysed. DGF was found in 19% (193/1015) of the low RI group and in 42.8% (337/787) of the high RI group (RR 2.04 (95% CI 1.72 - 2.41), p < 0.00001, I2 = 28%). IGF was found in 39.5% (62/157) of the low RI group and in 10.5% (28/268) of the high RI group (RR 0.26 (95% CI 0.17 – 0.40), p < 0.00001, I2 = 0%). Long-term graft survival, with follow up between 60-144 months, was found in 83% (701/845) of the low RI group and in 69.4% (395/569) of the high RI group (RR 0.82 (95% CI 0.72 – 0.93), p = 0.002, I2 = 63%). Conclusion: the results of this study emphasise the association between early measurement of RI and early graft function, and long-term graft survival. An elevated RI provides the chance of recognizing the patients with poor long-term prognosis, from the first moment after kidney transplant.


kidney transplant; resistive index; graft function


Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Eng J Med. 1999;341(23):1725-30.

Landreneau K, Lee K, Landreneau MD. Quality of life in patients undergoing hemodialysis and renal transplantation: a meta-analytic review. Nephrol Nurs J. 2010;37(1):37-44.

Laupacis A, Keown P, Pus N, et al. A study of the quality of life and cost-utility of renal transplantation. Kidney Int. 1996;50(1):235-42.

Mikhlaski D, Wissing KM, Ghisdal L, et al. Cold ischemia is a major determinant of acute rejection and renal graft survival in the modern era of immunosuppression. Transplantation. 2008;85(Suppl 7):S3-9.

McLaren AJ, Jassem W, Gray DW, et al. Delayed graft function: risk factors and the relative effects of early function and acute rejection on long-term survival in cadaveric renal transplantation. Clin Transplant. 1999;13:266-72.

Sidiqqi N, McBride MA, Hariharan S. Similar risk profiles for post-transplant renal dysfunction and long-term graft failure: UNOS/OPTN database analysis. Kidney Int. 2004;65:1906-13.

Kolonko A, Chudek J, Zejda JE, et al. Impact of early kidney resistance index on kidney graft and patient survival during a 5-year follow-up. Nephrol Dial Transplant. 2012;27:1225-31.

Quiroga I, McShane P, Koo DD, et al. Major effects of delayed graft function and cold ischaemia time on renal allograft survival. Nephrol Dial Transplant. 2006;21:1689.

Johnston O, O’Kelly P, Spencer S, et al. Reduced graft function (with or without dialysis) vs immediate graft function-a comparison of long-term renal allograft survival. Nephrol Dial Transplant. 2006;21:2270.

Rodrigo E, Fernandez-Fresnedo G, Ruiz JC, et al. Similar impact of slow and delayed graft function on renal allograft outcome and function. Transplant Proc. 2005;37:1431.

Gonwa TA, Mai ML, Smith LB, et al. Immunosuppression for delayed or slow graft function in primary cadaveric renal transplantation: use of low dose tacrolimus therapy with post-operative administration of anti-CD25 monoclonal antibody. Clin Transplant. 2002;16:144.

Król R, Chudek J, Kolonko A, et al. Intraoperative resistance index measured with transonic flowmeter on kidney graft artery can predict early and long-term graft function. Transplant Proc. 2011;43:2926-9.

Radermacher J, Mengel M, Ellis S, et al. The renal arterial resistance index and renal allograft survival. N Engl J Med. 2003;349(2):115-24.

Enhesari A, Mardpour S, Makki Z, et al. Early ultrasound assessment of renal transplantation as the valuable biomarker of long lasting graft survival: a cross-sectional study. Iran J Radiol. 2014;11:e11492.

Krumme B, Hollenbeck M. Doppler sonography in renal artery stenosis: does the resistive index predict the success of intervention? Nephrol Dial Transplant. 2007;22:692-6.

Keogan MT, Kliewer MA, Hertzberg BS, et al. Renal resistive indexes: variability in Doppler US measurement in a healthy population. Radiology. 1996;199:165-9.

Heine GH, Girndt M, Sester U, et al. No rise in renal Doppler resistance indices at peak serum levels of cyclosporine A in stable kidney transplant patients. Nephrol Dial Transplant. 2003;18(8):1639-43.

Krumme B, Grotz W, Kirste G, et al. Determinants of intrarenal Doppler indices in stable renal allografts. J Am Soc Nephrol. 1997;8(5):813-6.

Pape L, Mengel M, Offner G, et al. Renal arterial resistance index and computerized quantification of fibrosis as a combined predictive tool in chronic allograft nephropathy. Pediatr Transplant. 2004;8(6):565-70.

Naesens M, Heylen L, Lerut E, et al. Intrarenal resistive index after renal transplantation. N Eng J Med. 2013;369:1797-806.

Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology (MOOSE) group. Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA. 2000;283:2008-12.

Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of meta-analyses of randomized controlled trials: the QUORUM statement. Onkologie. 2000;23:597-602.

Hayden JA, Cote P, Bombardier C. Evaluation of the quality of prognosis studies in systematic reviews. Ann Intern Med. 2006;144:427-37.

Mwipatayi BP, Suthananthan AE, Daniel R, et al. Relationship between ‘immediate’ resistive index measurement after renal transplantation and renal allograft outcomes. Transplant Proc. 2016;48:3279-84.

Contti MM, Garcia PD, Kojima CA, et al. Quantified power Doppler as a predictor of delayed graft function after renal transplantation. Int Urol Nephrol. 2015;47:405-12.

Rodrigo E, López-Rasines G, Ruiz JC, et al. Determinants of resistive index shortly after transplantation: independent relationship with delayed graft function. Nephron Clin Pract. 2010;114:c178-86.

Saracino A, Santarsia G, Latorraca A, et al. Early assessment of renal resistance index after kidney transplant can help predict long-term renal function. Nephrol Dial Transplant. 2006;21:2916-20.

McArthur C, Geddes CC, Baxter GM. Early measurement of pulsatility and resistive indexes: correlation with long-term renal transplant function. Radiology. 2011;259(1):278-85.

Akgul A, Ibis A, Sezer S, et al. Early assessment of renal resistance index and long-term renal function in renal transplant recipients. Ren Fail. 2009;31:18-24.

Barba J, Rioja J, Robles JE, et al. Immediate renal Doppler ultrasonography findings (<24 h) and its association with graft survival. World J Urol. 2011;29:547-53.

Perrela RR, Duerinckx AJ, Tessler FN, et al. Evaluation of renal transplant dysfunction by duplex Doppler sonography: a prospective study and review of the literature. Am J Kidney Dis. 1990;15:544.

Berland LL, Lawson TL, Adams MB, et al. Evaluation of renal transplants with pulsed Doppler duplex sonography. J Ultrasound Med. 1982;1:215.

Nezami N, Tarzamni MK, Argani H, et al. Doppler ultrasonographic indices after renal transplantation as renal function predictors. Transplant Proc. 2008;40:94-9.

Quarto di Palo F, Rivolta R, Elli A, et al. Relevance of resistive index ultrasonographic measurement in renal transplantation. Nephron. 1996;73:195-200.

Tirotta A, Caviglia PM, Repetto M, et al. Resistive index and antihypertensive therapy in kidney transplantation. Arch Ital Urol Androl. 2005;77:54-7.

Tarzamni MK, Argani H, Nurifar M, et al. Vascular complication and Doppler ultrasonographic finding after renal transplantation. Transplant Proc. 2007;39:1098-102.

Chiang YJ, Chu SH, Chuang CK, et al. Resistive index cannot predict transplant kidney function. Transplant Proc. 2003;35:94-5.

Heine GH, Gerhart MK, Ulrich C, et al. Renal Doppler resistance indices are associated with systemic atherosclerosis in kidney transplant recipients. Kidney Int. 2005;68:878-85.

Schwenger V, Keller T, Hofmann N, et al. Color Doppler indices of renal allografts depend on vascular stiffness of the transplant recipients. Am J Transplant. 2006;6:2721-4.

Trillaud H, Merville P, Tran Le Linh P, et al. Color Doppler sonography in early renal transplantation follow-up: resistive index measurements versus power Doppler sonography. AJR Am J Roentgenol. 1998;171:1611-5.

Dupont PJ, Dooldeniya M, Cook T, et al. Role of duplex Doppler sonography in diagnosis of acute allograft dysfunction-time to stop measuring the resistive index?. Transpl Int. 2003;16:648-52.

Chudek J, Kolonko A, Król R, et al. The intrarenal vascular resistance parameters measured by duplex Doppler ultrasound shortly after kidney transplantation in patients with immediate, slow, and delayed graft function. Transplant Proc. 2006;38:42-5.

Full Text: PDF


  • There are currently no refbacks.