*Purpose: Early steroid withdrawal (ESW) regimens may lead to the formation of de novo donor-specific antibodies (dnDSA) post-kidney transplant, which increases the risk of antibody-mediated rejection. The aim of this study was to evaluate the incidence of dnDSA post-kidney transplant in patients receiving ESW regimens versus steroid-containing regimens.

*Methods: In this retrospective, single-center, cohort study, all patients who received a kidney transplant at Temple University Hospital (TUH) between 08/06/16 – 10/30/20 were included. Patients received steroid-containing regimens (control cohort [CC]) if considered high immunologic risk defined as the presence of at least one of the following: calculated panel-reactive antibody (cPRA)>30%, pre-existing DSA, positive crossmatch, re-transplant, HIV positive, or delayed graft function. Patients not meeting any of these criteria were deemed low immunologic risk and received ESW regimens. Patients were excluded if they received a multi-organ transplant. The primary and secondary endpoints were to identify the incidence of dnDSA, biopsy proven acute rejection (BPAR), graft failure, graft function, patient survival, and occurrence of common steroid-related adverse events at 12 months post-transplant (hemoglobin A1c, total cholesterol, low density lipoprotein, and change in weight).

*Results: A total of 156 patients were included with a mean follow up time of 12 months (ESW [N=59]; CC [N=97]). Baseline characteristics are listed in the table below. Mean weight-based rabbit-derived antithymocyte globulin (rATG) doses were 4.2 mg/kg and 5.1 mg/kg in the ESW and CC groups, respectively (p=0.03). A lower incidence of deceased donor transplants was noted in the ESW group vs. CC group (76% vs. 93%; p=0.006). In the CC group, 39% of patients had cPRA>30%, mean cPRA was 83% and 43% experienced DGF. The formation of dnDSA within 12 months post-kidney transplant was similar between groups (10% vs. 14%; p=0.62). There were no statistically significant differences in graft function, graft failure, patient survival, BPAR or steroid-related adverse events within 12 months post-transplant.

*Conclusions: Kidney transplant patients receiving ESW regimens were not at higher risk of developing dnDSA compared to patients receiving chronic steroids. However, given the majority of patients meeting criteria for high immunologic risk, this favors using chronic steroids in the high-risk population to avoid formation of dnDSA without an increased risk of steroid-related adverse events.

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