*Purpose: There has been conflicting reports on the impacts of the timing of acute rejection (AR) (early vs late) on the overall outcome of a kidney allograft. Likewise, African American receiving kidney transplant are often considered high risk for poor outcome based on published studies mostly including patients on steroid based immunosuppressive regimen. Since 2003, Indiana University has adopted an Early Steroid Protocol(ESW), we aim to report clinical outcomes based on timing of acute rejection and race in our patient population

*Methods: Retrospective chart review was done on recipients of kidney or simultaneous Kidney-Pancreas transplants between January 2005 and December 2015 at Indiana University. Patient with positive flow cytometry, multi-organ transplant were excluded. All patients received anti-thymocyte globulin (except zero mismatches) with steroid induction followed by a rapid taper (5 days), then maintained on 2 Immunosupression medications.

*Results: A total of 2196 patients (444 African Americans/AA and 1752 None African American/N-AA) were included in the study with a mean follow up of 5.4+/- 3.1 years. Steroid withdrawal was successful 80% and 97% at 1 month and 1 year respectively. HLA mismatch, DGF rate and history of previous transplant were similar between AA and N-AA. Cumulative 1 Yr AR in the study population was 9.7%.Overall graft survival was 93.8% at 3 years, 86.8% at 5 years Overall graft survival is worse with AR irrespective of the timing (<3 Month vs <1 Yr but >3 Month or >1 Yr) or with race(p<0.0001) . 1 Yr AR was significantly higher in AA vs N- AA (13.3% vs 8.8%, p=0.005. While overall DCGS is higher in AA vs N-AA (p<0.0005), there is however no graft survival difference in the presence of 1 Yr AR(p=1.83).Overall patient survival is comparable between AA- and N-AA. Patient survival is however worse in both AA and N-AA with 1 Yr AR when compared to those of the same race without 1 Yr AR (p<0.0005). Furthermore, there is a greater risk for death in AA with 1 Yr AR compared to N-AA with similar history (p<0.0001) $$graphic_

*Conclusions: : In this cohort of patient receiving ESW protocol with largest AA population included. AR remains a significant risk for both graft failure and death irrespective of race. These findings are consistent with prior reports in patient receiving steroid based Immunosupression.AA on ESW protocol appears to be at a greater risk for worse DCGS and death (in the presence of 1 Yr AR) when compared to non AA. Likewise, our study also suggests AR irrespective of the timing is associated with overall poor outcome.

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