*Purpose: Early Steroid Withdrawal (ESW) Immunosuppression protocol has become a viable alternative to steroid based regimen. Our transplant program has adopted ESW protocol since 2003 and hereby present 11 years of our experience.

*Methods: A retrospective chart review of kidney transplant recipients at Indiana University Transplant between 2005 and 2016 was done. Patients with multi-organ transplant follow up time &lt 1 year, or primary kidney transplant failure was excluded from the analysis. All patients received anti-thymocyte globulin as well as pulse steroid induction regimen except for those with 0 antigen mismatch who received basiliximab induction. Patients were weaned off steroid by day 4 and chronically placed on 2 immunosuppression medication regimens.

*Results: 2097 patients were included in the final analysis with a mean follow up time of 6.4 years. Mean age at transplant was 51 years, 60.1% were recipients of deceased donor kidney, 21.8% were African Americans , 15.6% were repeat transplant, 10.3%% had cPRA > 50%, 8% had positive flow cytometry crossmatch, 74.2% were on dialysis before transplant with 45% having been on dialysis for > 3 years. 13.5% were steroid dependent at 1 year. Overall 1 Yr AR was 16.1%. 5 Yr survival probability for DCGS is 96.6% (95% CI: 96-97%) and for 5 yr patient survival is 89.2 %(95% CI: 88-91%). Compared to those without rejection at 1 Yr, those with 1 yr AR had significantly lower probability of DCGS (5 yr: 91% vs. 98) and patient survival (5 yr: 83.5 vs 91.9%, p<0.0001, Figures 1,2). Compared to recipients of living donor kidney, recipients of deceased donor kidney had significantly lower survival probability (5 years: 87.5% vs 91.5%, p<0.0001) but no significant difference in DCGS probability (p=0.1970). Subgroup analysis by ethnicity showed African Americans have significantly higher 1 Yr AR and lower survival probability for 5 Yr DCGS and Patient survival when compared to the Caucasian (p < 0.0001).

*Conclusions: Although, ESW immunosuppression protocol may be associated with slightly increased risk for 1 Yr. AR when compared to published data on steroid based regimen, our data overall shows DCGS and patient survival in the intermediate term highly favors ESW approach.

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