To evaluate the usefulness of the monophosphate/inorganic phosphate ratio (MP/Pi) in assessing renal viability in a renal transplantation setting, we monitored intracellular phosphorous metabolites of 33 canine kidneys by phosphorus-31 magnetic resonance spectroscopy (MRS) after various amounts of ischemia. Renal viability (adequate perfusion and function) was directly assessed by the presence of intraoperative urine production in each kidney. Twelve normal, well-perfused kidneys (Group 1) exhibited high control MP/Pi ratios, with a mean of 0.87 +/- 0.12. Six in situ kidneys (Group 2), subjected to 45 minutes' warm ischemia followed by reperfusion, had a mean MP/Pi ratio of 0.50 +/- 0.12 after warm ischemia, which increased by a mean of 0.50 +/- 0.11 (to 1.0 +/- 0.07) after two to four hours of reperfusion. Fifteen kidneys (Group 3) were removed, cold-flushed and transplanted after 24 hours of hypothermic storage. In eight (Group 3A), reperfusion was excellent; in seven (Group 3B), reperfusion was inadequate secondary to hypotension in two, hemorrhage in two, and renal vein thrombosis in three. Group 3A kidneys had a mean MP/Pi ratio after cold-storage ischemia of 0.54 +/- 0.08. After successful transplantation and two to four hours of reperfusion, this increased by a mean of 0.23 +/- 0.12 to 0.77 +/- 0.15. Group 3B kidneys all showed a continuous decline of MP/Pi, with a mean loss of 0.26 +/- 0.09 from baseline values (mean 0.56 +/- 0.08) to nonviable levels of 0.28 +/- 0.12 within four hours of transplantation. We conclude that MP/Pi ratios enable assessment of renal viability and ischemic damage and can predict the efficacy of renal preservation maneuvers in the dog kidney. These preliminary data support the theory that MRS can be applied to the noninvasive assessment of viability in ex vivo, cold-stored cadaveric human kidneys awaiting renal transplantation.