Percutaneous Biopsy Under Deep Intravenous or Oral Conscious Sedation: Which Is the Best Option for Pediatric Renal Transplant Recipients?

Background: Renal allograft biopsy is essential in the follow-up of pediatric kidney transplant recipients, but the optimal sedation strategy remains uncertain. Methods: We retrospectively reviewed 711 ultrasound-guided biopsies in 251 children and adolescents (2009–2024), comparing oral conscious sedation with midazolam to deep intravenous (IV) sedation with propofol, midazolam, and ketamine. Outcomes included tissue yield, diagnostic success, complications, and cost-effectiveness. Results: IV sedation was used in 77.1% of procedures and was associated with longer cortical cores (median 1.8 vs. 1.5 cm, p < 0.001) and more glomeruli (16 vs. 8, p < 0.001), improving tissue yield and consequently increasing diagnostic success from 75% to 88.5% (p < 0.001; OR 2.6). Biopsy-related complications occurred in 12.9% of cases, with no difference between groups. Sedation-related complications, all mild or moderate, occurred only with IV sedation (4.9%). The improved tissue yield reduced the cost per successful diagnosis (EUR 1243 vs. EUR 1467), making IV sedation the dominant strategy. Conclusions: IV sedation enhances the diagnostic quality and cost-effectiveness of pediatric kidney allograft biopsies without increasing overall risk, though prospective studies should also assess patient anxiety and comfort.