*Purpose: Steroid withdrawal within the first month of kidney transplant (KT) remains controversial and has demonstrated a higher risk of acute rejection. The impact of induction and risk of biopsy proven acute rejection (BPAR) remains conflicting in the literature. We compared the risk of BPAR among KT patients receiving induction with basiliximab (BAS) and antithymocyte globulin (ATG) with and without steroids at our center.

*Methods: Adult KT recipients between 11/1/17 and 5/31/19 were prospectively reviewed in this single-center cohort study. Primary outcome was incidence of BPAR at 1 month post-transplant. Secondary outcomes included incidence of delayed graft function (DGF), cytomegalovirus (CMV) infection, and BK viremia over an average follow-up period of 6 months. Chi-square and logistic regression analyses were performed.

*Results: Of 151 KT performed, 64 patients received BAS induction, 87 patients received ATG. Steroids were withdrawn in 33 BAS patients and 34 ATG patients. There were significantly higher rates of 1 month BPAR in patients receiving BAS with and without steroids compared to ATG (Figure). In multivariate logistic regression analysis, type of induction agent was predictive of 1 month BPAR with BAS carrying a higher risk of developing BPAR at 1 month. Steroid continuation, DGF, and tacrolimus levels at various time points were not predictive of 1 month BPAR. Rates of DGF (34.4% vs. 29.9%; p=0.56), CMV infection (7.8% vs. 17.2%; p=0.09), and BK viremia (12.5% vs. 20.7%; p=0.19) were not significantly different between BAS and ATG cohorts. Rejection rates at 3 and 6 months post-KT normalized between the groups. During follow-up, there was 1 graft loss (technical) and 4 deaths (malignancy, pulmonary embolism, 2 unknown).

*Conclusions: There was a significantly higher rate of 1 month BPAR in the BAS cohort. Choice of induction agent has more of an impact on 1 month BPAR than steroid withdrawal.

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