Object: To demonstrate that adenosine triphosphate (ATP), which provides a valuable biomarker for kidney viability in the context of donation after cardiac death (DCD) transplantation, can be detected by means of 31P magnetic resonance spectroscopy (MRS) if kidneys are perfused with oxygenated hypothermic pulsatile perfusion (O2+HPP). Materials and methods: Porcine kidney perfusion was carried out using a home made, MR-compatible HPP-machine. Consequently, kidney perfusion could be performed continuously during magnetic resonance imaging and magnetic resonance spectroscopy recording. 31P MR spectroscopy consisted of 3-dimensional chemical shift imaging (CSI), which allowed for the detection of ATP level in line. 31P CSI was performed at 3tesla in 44min with a nominal voxel size of 6.1cc. Results: 31P CSI enabled the detection of renal ATP when pO2 was equal to 100kPa. With pO2 of 20kPa, only phosphomonoester, inorganic phosphate and nicotinamide adenine dinucleotide could be found. Semi-quantitative analysis showed that ATP level was 1.3mM in normal kidney perfused with pO2 of 100kPa. Conclusions: This combined technology may constitute a new advance in DCD organ diagnostics prior to transplantation, as it allows direct assessment of ATP concentration, which provides a reliable indicator for organ bioenergetics and viability. In this study, kidneys presenting no warm ischemia were tested in order to establish values in normal organs. The test could be easily integrated into the clinical environment and would not generate any additional delay into the transplantation clinical workflo
