*Purpose: About 15% of kidney transplant (KT) recipients receive alemtuzumab (ALM) for induction. The aim of this study was to review outcomes in living donor renal transplant recipients (LDRTs) who received ALM.

*Methods: LDRTs at a single center who received ALM for induction from 06/2017-09/2018 were included. LDRTs with PRA >20%, EPTS >75%, or re-KTs were excluded. Patients (pts) received steroids for 5 days, mycophenolic acid (MPA), and tacrolimus. Prophylaxis included TMP/SMX and valganciclovir (VG) for 6 months in high risk (CMV D+/R-) and 3 months in intermediate risk (CMV R+). Protocol management of neutropenia consists of reducing MPA and holding VG if ANC <1.0 K/µL. If ANC <0.5 K/µL, MPA and VG are held.

*Results: A total of 46 LDRTs with a mean follow-up of 230.5+112.1 days (range 73-502) were included. Baseline characteristics are described in Table 1. Mean Scr day of discharge, 90 days post-KT, and at last follow-up was 1.58+0.61, 1.53+0.40, and 1.54+0.43 mg/dL, respectively. Leukopenia was common; 72% had WBC <2.5 K/µL post-KT, 11% had WBC <1.0 K/µL. For neutropenia, 20% had ANC <1.0 K/µL and 9% had ANC <0.5 K/µL. Half of LDRTs had at least one MPA dose decrease per protocol (Figure 1). Average POD of MPA change was 81.5+49.5 days after KT (average WBC 1.54+0.43 K/µL, ANC 0.99+0.56 K/µL). Despite MPA decrease, only 3 episodes of rejection occurred. One pt had 2 episodes of Banff Grade 1B rejection on POD 114 and 248. One pt had subclinical rejection with positive DSAs on POD 30. Seven had positive DSAs post-KT; 5/7 had decreased MPA. Additionally, VG was held for leukopenia. For pts at high risk for CMV (n=5), 1 pt (20%) discontinued VG on POD 169 for leukopenia (WBC 2.8 K/µL). For pts at intermediate risk for CMV (n=28), 7 pts (25%) discontinued VG on average POD 61+21.7 for leukopenia (average WBC 1.66+1.0 K/µL and average ANC 1.21+1.1 K/µL). A total of 2 pts, both intermediate risk, developed CMV DNAemia. Other infections were also not common: UTI (n=4), BK viremia (n=3), parvovirus (n=1), EBV (n=1), HSV (n=1), pneumonia (n=1), candida esophagitis (n=1). At time of follow-up, pt and graft survival is 100%.

*Conclusions: LDRTs who received ALM experienced significant leukopenia. Despite 50% of pts requiring decreased MPA, rejection rates were low; however dose reduction may lead to development of DSA with unknown long term effects.

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