Utility and Cost-effectiveness of Surveillance Biopsies

PURPOSE OF REVIEW: The role of surveillance (protocol) biopsies in kidney transplantation remains controversial. Historically used to detect subclinical rejection before functional decline occurs, their utility must now be reassessed in the context of modern immunosuppression, evolving donor and recipient profiles, expanding therapies for recurrent kidney disease, and the emergence of noninvasive biomarkers. This review examines the effectiveness and cost-effectiveness of surveillance biopsies and proposes a pragmatic framework for their clinical use. RECENT FINDINGS: The prevalence of subclinical rejection has declined substantially in the modern immunosuppression era, particularly among recipients without donor-specific antibodies. Most lesions detected on surveillance biopsies now represent borderline or mild T-cell-mediated rejection or mild microvascular inflammation and the benefit of treating these findings remains uncertain. At the same time, surveillance biopsies continue to provide important diagnostic information, including early evidence of chronic injury, donor-derived disease, and recurrent primary kidney diseases. Decision-analytic models indicate that the cost-effectiveness of screening strategies depends heavily on recipient age, immunologic risk, and the likelihood that detected pathology will meaningfully alter management. Emerging non-invasive biomarkers offer promising adjuncts, but they cannot fully replace histological evaluation. SUMMARY: Routine surveillance biopsies for all kidney transplant recipients are unlikely to represent the most efficient monitoring strategy. A risk-stratified approach integrating immunologic risk, clinical context, dynamic changes in immunosuppression, and selective use of biomarkers may optimize detection of clinically meaningful injury while minimizing unnecessary procedures and healthcare costs.