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

<b>Background:</b> Renal allograft biopsy is essential in the follow-up of pediatric kidney transplant recipients, but the optimal sedation strategy remains uncertain. <b>Methods:</b> 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. <b>Results:</b> IV sedation was used in 77.1% of procedures and was associated with longer cortical cores (median 1.8 vs. 1.5 cm, <i>p</i> < 0.001) and more glomeruli (16 vs. 8, <i>p</i> < 0.001), improving tissue yield and consequently increasing diagnostic success from 75% to 88.5% (<i>p</i> < 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. <b>Conclusions:</b> 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.