*Purpose: Evaluate the effects of donor specific antibodies (DSAs) on outcomes in post-intestinal/multivisceral (MV) transplant patients and describe the presentation of DSAs post-transplant.

*Methods: This single-center retrospective review included all intestinal/MV transplant recipients from 1/1/15-9/31/17 who had DSA testing post-transplant. DSA monitoring was variable and dependent on medical team discretion, although serial DSA monitoring (weekly for at least 3 weeks post-transplant) was completed for a portion of the cohort. Patients were divided into groups based on the presence of DSA post-transplant. The primary outcome was biopsy-proven acute rejection (BPAR). Secondary outcomes included graft loss and death. Descriptive analysis of DSAs was completed.

*Results: This study included thirty-five intestinal/MV transplant recipients (60% pediatric). Twenty-four patients had post-transplant DSA (DSA(+) group) while 11 did not (DSA(-) group). Serial monitoring occurred in 54% of the DSA(+) group and 45% of the DSA(-) group (p=0.72). BPAR occurred in 15 patients in the DSA(+) group and in 5 in the DSA(-) group (63% vs 45%, p=0.47). Time to BPAR was earlier for the DSA(+) group (25 days (IQR 19-165) vs 232 (IQR 25.5-632.5), p=0.07). Four patients in the DSA(+) group had multiple BPAR episodes compared to none in the DSA(-) group (17% vs 0%, p=0.28). There were no differences between groups for graft loss or death. Excluding duplicate DSAs within individual patients, 96 post-transplant DSAs were identified; most were de novo (80%) and Class II (64%). Forty-five unique DSAs were found; the most common HLA-class was DQ (35%). Time to first DSA did not differ between Class I and Class II (18.5 days (IQR 12.5-22) vs 18 (IQR 10-25), p=0.77). Clearance occurred for 42 of the 96 DSAs with no difference between Class I and Class II (46% vs 39%, p=0.66). Time to clearance was 38 days (IQR 15.5-59.5) for Class I and 28 (IQR 15-63) for Class II (p=0.93). Clearance of all DSAs occurred in 4 patients (17%).

*Conclusions: The presence of DSA post-intestinal/MV transplant did not result in statistically different BPAR rates. Findings that DSA presence may lead to shorter time to BPAR may be of clinical significance, though this was not statistically significant. Most DSAs were found within the first month post-transplant. Early serial DSA monitoring may be warranted to allow for early detection and possibly better management to prevent potential negative outcomes related to their presence.

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