*Purpose: Transplantation across a positive flow crossmatch (+FXM) has been established as a lifesaving measure in the living donor setting. Time required for desensitization limits utility in deceased donor transplants (DDTx). We report outcomes of +FXM DDTx recipients using conventional and modified desensitization applied in the postoperative setting.

*Methods: Adult +FXM DDTx recipients from 7/2018 to 6/2020 were analyzed. Crossmatch was done by local HLA lab or organ procurement organization. No patients received waitlist desensitization. Standard of care was Plasmapheresis(PP)/Thymoglobulin 2.5mg/kg (IBW) on POD0,1,3,5,7,9 and IVIG 150mg/kg (IBW) on POD2,4,6,8. A subset of patients received PP/bortezomib 1.3mg/m² on POD1,4,8,11 and Thymoglobulin 1.5mg/kg (IBW) on POD0-4. Discharge IS consisted of TAC, MPA, and prednisone.

*Results: Twenty six patients received +FXM DDTx. All had negative standard XM. Majority (92.3%) received isolated kidney, were female (57.7%) and black (46.1%). Table 1 details demographic and IS. T cell +FXM was present in 73.1% cases, and B cell +FXM in 80.8% cases. Patient outcomes are provided in Table2. Three patients (11.5%) experienced delayed graft function. Four patients (16%) received rejection treatment (1/BPAR requiring IVIG/PP/Thymoglobulin; and 3/with steroids). At 6 months, mean eGFR was 57+/- 34.9 ml/min. Patients with longer follow up showed stable eGFR out to 24 months (Figure 1). Majority (69.2%) remained on TAC/MPA/Pred at last follow up. Seven patients (27%) required IS manipulation (4 for infection [57.2%] and 2 for leucopenia [28.6%]). Two patients died, both due to infection related complications; neither experienced rejection. Serial DSA screening was performed in 92.3% cases, with 54% showing negative Class I and 75% showing negative Class II DSA at last follow up, Table 3. Majority of patients had a decline in both Class I (72.7%) and Class II (54.5%) DSA strength index at last follow up.

*Conclusions: Decreased donor transplantation across +FXM may be an option for a select group of patients but requires close monitoring and swift IS modification to ensure optimal outcomes.

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