Editors,

We have carefully read the study published by Tisljar et al. on the effect of the pelvi-ureteric junction dysfunction (PUJ) on the outcome of kidney transplant from living donors [1]. There is an urgent need to expand the donors’ criteria to match the increasing demand for the organs available for transplantation [2]. Nevertheless, it is crucial to weigh the inevitable challenge of harming donors on one hand and saving lives of renal failure patients on the other hand [3]. George et al. reported PUJ complications occurred after about 6 years from kidney transplant [4]. While Doehn et al. reported ureteral complications occurred after 2129 days [5]. These periods were far more than the follow-up time reported by Tisljar et al [1]. Moreover, the retrospective nature of the aforementioned study limits the ability to produce any causal interpretation. We agreed with the authors that more prospective randomized long-term trials are needed to test their findings.

Finally, they did not assess the degree of PUJ or related vascular anatomic variations, which have pivotal implications in surgical approaches [6]. More severe degrees of PUJ might have different outcomes. The urge to minimize the gap between the number of candidates on the kidney transplant waitlist and the available leads to a tendency to relax the criteria of accepting more marginal donors and the increased utilization of surgically complex living donors. Nonetheless, more studies are needed to address the short- and long-term complications and outcomes for accepting candidates with PUJ dysfunction. A highly valid scoring system is urgently needed to expect the post-donation health hazards among those candidates, which assure the safety of those candidates.