*Purpose: While pediatric liver transplantation (LT) results in excellent long-term outcomes, a high incidence of early acute cellular rejection (ACR) and late graft fibrosis persists. Routine liver function tests may not reliably detect rejection episodes or identify patients who are candidates for reduced/modified immunosuppression (IS). Surveillance biopsies (SB) can provide valuable information in this regard, but their role in pediatric LT continues to be controversial.

*Methods: A retrospective cohort of 232 pediatric LT recipients who underwent biopsy between 2003-2019 was studied to characterize the potential risks and benefits of SB vs ‘for cause’ biopsies. At our center, SB was performed ≥5 years post-LT with stable graft function or 1-year post biopsy-proven ACR.

*Results: Among 816 biopsies obtained from 232 patients, 150 (18%) were SB. Only 6 (0.7%) of patients in the entire cohort had a biopsy-related complication, and none were observed in the SB subset. Liver function tests did not predict rejection severity on biopsy (ALT AUROC 0.65 (very poor prediction), Bilirubin AUROC 0.58 (no prediction), GGT AUROC 0.56 (no prediction)). SB identified a subclinical rejection episode in 18.6% of biopsies. When obtained within 24 months of LT, 7.7% of SB led to changes in IS, when obtained >24 months post-LT 18.7% prompted IS change including reduction. SB obtained <10-years post-LT trended toward higher incidence of ACR (Fig. 1A), with reversal at >10 years, although this was not significant (p=0.24). Graft survival and patient survival did not differ between SB and ‘for cause’ groups (Fig. 1B and C). 63% of SB had some evidence of fibrosis.

*Conclusions: In our experience, SB in pediatric LT have a good safety profile and provide valuable information about subclinical rejection episodes, leading to changes in management of IS. Further multi-center studies are needed to examine the role for SB on long-term outcomes in pediatric LT.

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