*Purpose: The optimal duration, as well as the dose of the initial steroid use, is not known as it varies widely among institutions that have adopted early steroid withdrawal ((ESW) regimens. Our Transplant program adopted ESW in 2003 utilizing an initial regimen of methylprednisolone 500 mg IV in the OR followed by prednisone 80 mg PO on POD 1, 40 mg PO on POD2, 20 mg PO on POD 3 then stop. In August 2017, the duration of the steroid wean was lengthened to include an additional 10 days of prednisone 10 mg for a total or 14 days of steroid for a total duration of 14 days of steroid therapy. We hereby report the clinical outcomes in our patients who have received 4 days vs 14 days of ESW.

*Methods: A retrospective chart review of kidney transplant recipients between August 2017 to October 2018 was conducted utilizing the electronic medical records. Patients with primary failure were excluded from the analysis. All recipients received induction therapy with rabbit antithymocyte globulin 6 mg/kg total dose and were maintained on a regimen of tacrolimus (goal trough 6-9 mCg/mL) in combination with mycophenolic acid following steroid withdrawal. Outcomes were compared between those who received 4 days (4D) vs 14 days (14D) ESW regimen.

*Results: A total of 374 patients (4D=186, 14D=188) were included in the final analysis with a mean follow up time of 973 days in the 4D group vs 576 days in the 14D group. There were no differences in the baseline demographics. 1 Year Biopsy Proven Acute Rejection (BPAR) was significantly higher in the 4D vs 14D group (24.2% vs 13% respectively=0.007). The presence of BK viremia or viruria (36% vs 15%, p=0.002) as well as mean time to BK infection (159 vs 477 days, p=<0.0005) was higher in the 14 D vs 4D, respectively. There were no significant differences between groups concerning CMV infection risk, GFR and proteinuria at 3M, 6M and 1 Year post transplant. Unadjusted as well as death censored graft survival (DCGS) 1Yr graft and patient survival rates were similar between groups.

*Conclusions: Fourteen day early steroid withdrawal is associated with a lower incidence of BPAR at 1 year compared to 4 day steroid withdrawal. However, it does not appear to have a significant benefit in the overall graft outcome in the short term and may be associated with greater risk of BKV infection.

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