Protocol biopsies should not (yet) be the standard of care in pediatric renal transplant recipients.

Editorial Protocol biopsies should not (yet) be the standard of care in pediatric renal transplant recipients The care and management of renal transplant recipients, and especially of pediatric renal transplant recipients, is potentially complex and exacting. Balancing the amount of immunosup-pression to prevent toxicity and to avoid rejection is not always straightforward. In addition, the specific needs of pediatric patients add another layer of complexity to their care. A reasonable question is whether routine protocol kidney biopsies (by definition, in patients with stable renal function) will help to optimize the management of pediatric kidney recipients, and whether the benefits justify making them the standard of care for all pediatric kidney recipients. I would argue that they do not, and that protocol biopsies should not yet be performed routinely in all patients. There is no question that obtaining renal allograft biopsies to evaluate renal dysfunction is essentially mandatory. Without a biopsy to establish the diagnosis, any therapeutic intervention is a poorly educated guess. However, the use of invasive biopsies to evaluate all children with stable renal function is another matter. It is certainly possible, even likely, that such biopsies, preferably in combination with mechanistic studies of immunologic reactivity, represent important research tools. They can reveal whether important subclinical events are occurring that can impact on long-term patient and graft survival. Such studies should be performed in selected centers with the manpower and expertise to perform protocol biopsies safely and routinely. It is even reasonable for a given center to consider them as its standard of care. At issue is whether the results from studies that have performed protocol biopsies justify their expansion to every pediatric kidney transplant program. 766 There is a fairly substantial literature on protocol biopsies in adult renal transplant recipients , and a smaller literature on pediatric recipients. These studies show a variable incidence of subclinical acute rejection, ranging from 2.6-100%, with many reports in the 25-30% range (1-18). There is also a literature demonstrating an incidence of subclinical chronic allograft nephropathy and a suggestion that the presence of CAN with vasculopathy is a poor prognostic factor for long-term outcome (8). However, the important issue in protocol biopsies is whether performing them will lead to management changes that will improve long-term graft survival and function. The only randomized trial that has demonstrated a benefit to diagnosing and treating subclinical acute rejection is the adult Winnipeg experience and, while …