The value of protocol biopsy as an important strategy in renal transplantation for assessing the histological changes regardless of graft function was previously explored through short-term studies. We aimed to assess its importance on a long-term basis. Protocol biopsies were done for 120 live donor renal transplant recipients with well functioning grafts and no-rejection history. The histopathological findings using chronic allograft damage index score (CADI) and banff classification were correlated with different parameters including the recipient's and donor's age and sex, donor-recipient relationship, degree of HLA matching, pretransplant hypertension, primary immunosuppression, presence of post transplant complications as hypertension and post transplant diabetes mellitus. Chronic tubulointerstitial fibrosis was the most prevalent finding being present in 75% of cases mostly mild degree. Normal biopsies were found in only 7.5% of cases whereas chronic cyclosporine nephrotoxicity was detected in 5.8% of biopsies. Hypertension was significantly correlated with glomerulosclerosis, periglomerular fibrosis and hyalinosis and diabetes with glomerular basement membrane (GBM) thickening, intimal proliferation and glomerulosclerosis. The main risk factors associated with high CADI score were DR mismatching and posttransplant diabetes mellitus. All histopathological changes increase with advancing of donor age and declining graft function. Protocol biopsy showed that histopathological findings do exist even with normal renal function that may pave the way for predicting the long term graft outcome.