*Purpose: To ascertain causes of allograft dysfunction, loss and death in a cohort of kidney transplant patients

*Methods: In this Retrospective cohort study, 943 patients who received isolated Kidney transplants between years 2013-17 were analyzed for the following transplant outcomes: 1. Death-censored allograft loss 2. Graft dysfunction 3. Death. Graft dysfunction was defined as eGFR persistently < 30 (More than 3 consecutive readings). Patients with dual organ transplant were excluded. Immunosuppression largely utilized Thymoglobulin induction followed by Tacrolimus and MMF maintenance with rapid steroid withdrawal.

*Results: Over 5 years of follow up, 80 of 943 (9%) patients died while 63 (7%) lost their graft and a further 38 (4%) suffered allograft dysfunction. Death- Although death was attributed largely to a combination of infection (29%), Cardiovascular (CV) disease (29%) and malignancy (12%), a significant proportion of patients who died from either CV disease (43%), infection (26%) or malignancy (20%) had prior biopsy proven T-Cell Mediated Rejection (TCMR) in 1^st post-transplant year, thus highlighting the significance of early TCMR as a major contributing factor to mortality. Graft Loss– In this cohort TCMR (39%) was the most widespread factor contributing to allograft loss. While Infection (17%) and surgical causes (14%) were the next common associations with graft loss, donor related disease accounted for only 2% of all graft losses. 8% patients who lost the graft had Antibody Mediated Rejection (ABMR) as a direct contributing factor. Graft Dysfunction- Again TCMR (42%) was strongly associated with allograft dysfunction in our patient cohort. The other factors associated with Allograft Dysfunction included a) Infection (21%) b). Donor Related causes (11%) and c). Other Causes (15%). Surprisingly ABMR was only noted in 11% of patients with allograft decline. Rejection and Non-Adherence-Because TCMR was a common contributing factor to all the three hard outcomes in our study cohort, we examined the factors associated with TCMR. 40% of patients with TCMR were found to be non-adherent (defined by > 3 consecutive sub- therapeutic CNI levels, clinic no shows and poor compliance to regular lab draws) noncompliance. Importantly, patients who were non adherent were significantly younger (mean age 38 y vs 55 y; p=0.0001) and a greater proportion of them were of African American (47% vs 22%;p=0.055) compared to those who were adherent to therapy.

*Conclusions: While the causes of death, early allograft loss and dysfunction were diverse, TCMR was the most dominant contributor. Non-Adherence was strongly associated with TCMR and was more common in younger patients and those with African American ethnicity. Addressing non adherence in this cohort of patients early with novel interventions could be a key to optimizing patient outcomes in this high risk cohort.

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