Pretransplant biopsies for kidney allocation and discard: more questions than answers

Kidney transplantation is the preferred treatment for end-stage kidney disease, but organ availability lags behind demand, resulting in prolonged waiting times and mortality on the waiting list. To address the shortage, transplant centers are increasingly using organs from higher-risk donors. The practice of performing pretransplant biopsies was established after Gaber et al. (19951) reported higher rates of delayed graft function and failure in grafts with >20% glomerulosclerosis. This was further reinforced by studies suggesting clinical benefit of evaluating pretransplant biopsies for kidney allocation decisions in the specific context of dual kidney transplantation.