How to perform a renal transplant biopsy: a practical guide for clinicians with CEUS-driven diagnosis and follow-up of complications

Percutaneous ultrasound-guided kidney biopsy remains the reference standard for diagnosing renal allograft dysfunction and for tailoring immunosuppression. Although major complications are uncommon in experienced hands, bleeding-related events and post-biopsy vascular lesions require a rapid, operational imaging and follow-up strategy. This practical guide provides a step-by-step, competency-based workflow for renal transplant biopsy—from indication setting and risk optimisation to room set-up, equipment selection, safe cortical targeting, and specimen adequacy criteria—followed by structured post-biopsy monitoring and discharge counselling. In this study, we will be conducting a comparative analysis of percutaneous, transvenous, and CT-guided approaches. Furthermore, we will be summarising pragmatic thresholds for blood pressure, coagulation parameters, and periprocedural antithrombotic management. A dedicated section integrates contrast-enhanced ultrasound (CEUS) into complication triage when grayscale ultrasound and Doppler are equivocal, defining practical triggers for escalation and follow-up pathways for haematoma, pseudoaneurysm, arteriovenous fistula, and segmental perfusion defects. The translation of imaging findings into actionable clinical decisions, facilitated by a protocolised biopsy technique in conjunction with CEUS-driven problem solving, has been demonstrated to enhance diagnostic confidence and improve safety in routine transplant care.