Protocol liver allograft biopsies

Protocol liver allograft biopsies are liver biopsies carried out at specific time points according to predetermined guidelines, rather than in response to specific indications such as change in the patient's clinical status or biochemical tests. Use of protocol liver allograft biopsy has been declining over the last decade: an informal survey of 35 transplant units showed that whereas 65% of units undertake protocol biopsies for those grafted for Hepatitis C virus infection, only 25% do so for patients grafted for other indications. In this overview, we consider the arguments against and those in favor of liver biopsies in adult liver allograft recipients. Arguments against the use of protocol liver biopsies are that they biopsies put the patient are associated with a small risk of morbidity and mortality, are expensive, do not provide useful information and do not alter clinical practice. The estimated rate of major complications is 0.6% and the estimated mortality rate 0.02%. However, the argument in favor of protocol biopsies is that even when standard liver tests are normal, there is on-going inflammation in the graft which, if immunosuppression is not altered, will lead to progressive fibrosis, cirrhosis and even graft loss. Conversely, normal liver histology may allow for reduction in the immunosuppression and so lower the risk of the complications associated with immunosuppression. Currently available diagnostic techniques are not yet sufficiently sensitive or specific to provide an accurate reflection of the state of the graft and the presence or absence of graft damage. We conclude that, while there are no clear data showing that protocol liver allograft biopsies are cost effective and lead to improved patient and graft outcome, such biopsies still have a role in the management of the liver transplant recipient.