Implementing systematic early protocol biopsies in routine practice: An exploratory real-world study

Acute rejection remains a major threat to long-term graft survival. Subclinical forms may go undetected without histological assessment, leading to progressive injury. This study evaluates the role of protocol biopsies in detecting subclinical rejection and preserving graft function and examines the prognostic significance of early histological findings and estimated glomerular filtration rate (eGFR) at discharge.

A retrospective, single-center study of kidney transplant recipients who underwent an early protocol biopsy. Clinical, immunological, and histopathological data were collected, including induction therapy, renal function (eGFR), and Banff inflammatory scores. Associations between histology, renal recovery, and long-term outcomes were analyzed.

Among the 99 patients, rejection was detected in 20.2%, predominantly T-cell mediated (90%). Early intervention significantly improved renal function, with a mean eGFR increase from 36.0±23.1 to 51.0±21.7 mL/min/1.73 m² (p<0.001). The change in eGFR (ΔeGFR) was significantly greater in patients with rejection compared to those without (11.1 vs 1.2 mL/min/1.73 m²; p<0.01). Higher eGFR at discharge was strongly associated with better long-term renal function (p<0.001).

Protocol biopsies are key for early detection of subclinical rejection, enabling timely intervention. Discharge eGFR strongly predicts long-term outcomes.