Surveillance Biopsy After Lung Transplantation — Is It Necessary?

Routine scheduled transbronchial surveillance biopsies allow for regular invasive assessment of allograft health and detection of alloimmune, infectious, inflammatory, or anastomotic conditions that may otherwise be clinically occult. An alternative approach to surveillance biopsies utilizes noninvasive assessments of allograft health and function combined with bronchoscopy when abnormalities are detected. There is an ongoing debate with reference to the merits and drawbacks of each approach.

A large majority of lung transplant programs employ surveillance biopsies.  While the safety and ability of this approach to identify occult cellular rejection are established, the impact on longer term outcomes remains unclear.  An alternative approach utilizing biopsy triggered by clinical indications is limited by the inability to detect occult rejection and reliance on spirometry which may be an insensitive and non-specific biomarker of allograft health. Newer non-invasive monitoring approaches particularly those employing donor-derived cell free DNA may further reduce reliance on surveillance biopsy.

The impacts of monitoring with or without surveillance biopsy on long-term graft and patient health and survival have not been compared in a scientifically rigorous matter. Newer diagnostic tools may ultimately enhance non-invasive assessment of graft function and decrease reliance on surveillance biopsy.  This article will review available evidence and evolution in post-transplant care to evaluate the rationale, advantages, and drawbacks of these two practices.