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Objectives: To assess retrospectively whether diffusion-weighted magnetic resonance imaging (DW-MRI) allows physicians to determine the severity of histopathologic findings in biopsies of renal allograft patients with deteriorating renal function.Methods: Forty consecutive kidney transplant patients underwent DW-MRI and biopsy. Patients were assigned to one group with severe and to another group with normal or mild histopathologic findings. These two groups were compared based on a qualitative DW-MRI assessment (homo-/heterogeneity) and the combination of qualitative and quantitative DW-MRI parameters (ADC, and intravoxel incoherent motion, IVIM, parameters: D, f, D*). Sensitivity, specificity, and accuracy were determined for each parameter.Results: Biopsy findings were severe in 25 patients and normal or mild in 15 patients. Qualitative DW-MRI led to a sensitivity of 44.0% and a specificity of 93.3%. Combined qualitative and quantitative DW-MRI led to an accuracy of 80% for both the minimal ADC (ADCmin) and the minimal perfusion fraction (fmin) with a sensitivity of 84.0% and 92.0% and a specificity of 73.3% and 60.0%, respectively.Conclusion: Combined qualitative and quantitative DW-MRI might allow physicians to determine the severity of histopathologic findings in biopsies of a high number of kidney transplant patients.Key Points: • Qualitative DW-MRI is highly specific when predicting the severity of kidney transplant biopsy. • Allografts appearing heterogeneous on ADC are associated with severe histopathologic findings. • Combining qualitative and quantitative DW-MRI parameters improves the classification's sensitivity and accuracy. • Kidney transplant biopsies might be spared by combining qualitative and quantitative DW-MRI. [ABSTRACT FROM AUTHOR]