*Purpose: Stablish the optimal technique and protocol of ultrasound guided renal graft biopsy to be performed by nephrologist compared with previous standard of care, regading technical issues and complications after procedure.

*Methods: From June 2013 to November 2017, Total of 483 US-guided kidney biopsies were performed in our institution. We decided to optimize biopsy protocol, from 24 hours admission and observation to outpatient protocol of 6 hours observation post-biopsy. Evolved from shared technique by radiologists and nephrologist together to US guided biopsy performed by the nephrologist alone. Changed 14 G biopsy needle to 16 G needle over the same period. We retrospectively analyzed results of those changes and compared each group

*Results: Total of 483 biopsies performed, 261 on renal grafts. Of them, 63 % by shared technique, 37% nephrologist alone. Outpatient protocol with 6 h of observation performed on 44% patients. 56 % underwent 24 h admission. Automatic biopsy gun 14 G used in 34,5%, 16 G 60 %, 18 G 5,5%. Mean age 55 ± 14, 65,5% male. Mean needle passes 2 ± 1, mean number of valid samples 1,5 ±0,5. Mean pre-biopsy hemoglobin 11,5 ± 1,8 gr/dl, post-biopsy 10,9 ± 1,9 gr/dl, and mean Hb change was 0,6 ± 0,67. Mean obtained glomeruli was 17 ± 11. 14 G Needle mainly used for inpatient protocol ( 62%) and for shared technique ( 49,7%),16 G biopsy gun mainly used in outpatient cases ( 57%) and in all nephrologist solo cases. Overall complications 10,8%, vast majority minor complications. Biopsies on renal grafts showed less complications rate compared to native kidneys ( 6,9% vs. 15,3%). Among renal grafts, complications higher in shared technique vs. Nephrologist alone ( 8,4 vs 4,1%), including when only 16 G were selected in both groups ( 4,1% Nephrologist vs. 8,5% radiologists). Not significant differences between the inpatient vs. outpatient cases ( 6,2 vs. 7,8%). More complications with 14 vs 16 G needle ( 12,2 vs. 4,2%), and with performance of 3 or more needle passes (16,6% vs. 5,9%). No nephrectomies or deaths during the study period. Diagnostic was achieved in 95,5% of all cases, despite high proportion obtained less than 10 glomeruli per sample both radiologists and nephrologist ( 22,4%, vs. 22,9%)

*Conclusions: Fewer complications using 16 G biopsy needle compared with 14 G, and when 2 or less passes were performed. No significant differences in complications between inpatient vs. outpatient with 6 h of observation. Less complications observed when biopsy performed by nephrologist alone compared with shared technique. US-guided renal graft biopsy using 16 G needle, with 6 hours observation after procedure and performed by nephrologist alone is safe, cost-saving, optimizes the renal graft biopsy process and might contribute to regain a procedure in jeopardy of being lost among nephrologists.

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