*Purpose: KAS forced centers to list unacceptable HLA antigens. Some centers excluded antigens at any level of anti-HLA Ab. Our center only excluded antibodies posing excess risk (ie mean fluorescence intensity [MFI] >3000). We hypothesized that the restriction in anti-HLA levels improved outcomes of +DSA DDRTx.

*Methods: We reviewed our database to identify +DSA DDRTx recipients from 1/1/2010-12/3/2014 (last day prior to KAS) and from 12/4/2014-8/31/2020. We recorded data on induction, anti-HLA DSA measured by Luminex®, rejection rates, renal function, graft loss and death.

*Results: 86 of 565 DDRT had DSA pre-KAS compared to 74 of 538 DDRT after KAS. Follow up was 6.35 (IQR 3.2-8) and 3.1 (IQR 1.2-3.9) years respectively (p < 0.001). Both groups had a similar % of women with similar ages but different induction strategies (Table 1). Our protocol +DSA pts changed during this time period, leading to more post-KAS patients getting IVIg/Rituximab induction to prevent AMR and more protocol biopsies (87% vs 23%, p <0.01). The type of anti-HLA Abs (class 1, 2, or both) were not different between groups but the DSA MFIs were significantly lower post-KAS. Rejection was more common post-KAS (81% vs 65%), which was entirely explained by the increased use of protocol biopsies. Patients transplanted post-KAS were diagnosed with AMR significantly later. ACR occured earlier and was significantly milder with more frequent borderline rejections. Despite the high rejection rate, kidney function at 1 year was excellent with no difference between groups (median 1.57 [IQR 1.26-2] mg/dL vs 1.42 [IQR 1.27-1.81], p 0.17). Death censored graft survival was not significantly different at 1 year (94.5% vs 98.7%) or at 3 years (84.8% vs 96%).

*Conclusions: Despite listing unacceptable HLA antigens postKAS, a similar percentage of our DDRTx had DSA, though at much lower MFI. The overall renal function is excellent and graft survival comparable to UNOS reported outcomes for DDRTx at 1 year (93.2%) and 3 years (85.1%).* These outcomes suggest that transplanting sensitized patients with low level MFI is worthwhile compared to continuing dialysis while awaiting an offer without DSA.

*https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/ accessed 12/3/2020

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