Kidney Week

Abstract: TH-PO1059

Effect of Per-Protocol Kidney Transplant Biopsies vs. Standard Care on Kidney Allograft Survival and Other Outcomes: A Systematic Review and Meta-Analysis

Session Information

• Transplantation: Clinical - Outcomes, Malignancy, and Pathology
  October 22, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Transplantation

• 2002 Transplantation: Clinical

Authors

• Razzouk, Ranim, American University of Beirut Medical Center, Beirut, Lebanon

Ranim Razzouk, MD

• Taha, Dana Mohamad, American University of Beirut Medical Center, Beirut, Lebanon

Dana Mohamad Taha, MD

• Hallak, Patrick E., American University of Beirut Medical Center, Beirut, Lebanon

Patrick E. Hallak, MD

• Harb, Frederic, University of Balamand Faculty of Medicine and Medical Sciences, Koura, Lebanon

Frederic Harb, MSc, PhD, MBA

• Cucchiari, David, Hospital Clinic de Barcelona, Barcelona, CT, Spain

David Cucchiari, MD, PhD

• Azzi, Jamil R., Brigham and Women's Hospital, Boston, Massachusetts, United States

Jamil R. Azzi, MD, PhD

• Mallat, Samir G., American University of Beirut Medical Center, Beirut, Lebanon

Samir G. Mallat, MD, MEd, FASN

Background

Kidney transplantation is the preferred treatment for end-stage kidney disease, but long-term graft survival remains suboptimal. Some centers use protocol biopsies to detect early subclinical injury, whereas others biopsy only when clinically indicated. This systematic review and meta-analysis evaluate whether protocol versus indication-based biopsy strategies improve graft survival and other key clinical outcomes.

Methods

We conducted a systematic search in Embase, PubMed, Medline, and Cochrane to identify randomized and non-randomized studies comparing per-protocol (intervention) with a per-indication biopsies policy (control). The primary outcomes included renal allograft survival, patient survival, graft function, modification of immunosuppressive treatment, and detection of BK nephropathy. Secondary outcomes encompassed early detection of subclinical rejection, borderline rejection, acute rejection, CNI toxicity, procedural complications, and glomerulonephritis. We calculated pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI), assessing heterogeneity across studies.

Results

Sixteen studies were included. Protocol biopsy strategies improved graft survival up to 30 months (OR 2.65, 95% CI 1.15–6.11), with similar patient survival and complication rates. They were associated with fewer reported acute rejection episodes, ABMR and TCMR, but more borderline rejection. Protocol biopsies also attenuated eGFR decline and reduced BK nephropathy and CNI toxicity.

Conclusion

Protocol biopsies were associated with improved early graft survival and renal function, likely reflecting the early detection of subclinical rejection and subsequent immunosuppressive adjustments. However, long-term benefit remains uncertain due to substantial heterogeneity and the predominance of observational data. Further well-designed randomized trials with larger sample sizes and extended follow-up periods are necessary to confirm long-term efficacy and cost-effectiveness.

Acknowledgment

The authors thank the clinical and research staff of the participating transplant centers for their support in data collection and patient follow up. We are also grateful to the Clinical Research Institute at the American University of Beirut for methodological input and logistical assistance.