*Purpose: Kidney transplantation among HIV+ recipients (HIV+ KT) is increasing, with excellent outcomes. Acute rejection (AR), however, is 2-3-fold more common than in HIV- KT. Steroid maintenance may reduce AR, yet exacerbate metabolic and infectious complications in HIV+ persons. We examined the relationship between early steroid withdrawal (ESW, discharge without steroid maintenance) and AR post-HIV+ KT.

*Methods: Using SRTR data from 2000-2017, 1400 first-time, kidney-only HIV+ KTs were identified (Image 1). We studied 1123 recipients who had no rejection or graft loss during transplant hospitalization, and were discharged on calcineurin inhibitors and mycophenolate (Table 1). Multivariable logistic regression tested for associations with AR.

*Results: 227 HIV+KT (20.2%) underwent ESW; a group with higher proportion of living donors (26% vs 19.2%), zero HLA mismatch (9.7% vs 3.8%), and lymphodepleting induction (65.2% vs 47.7%). Most recipients were black (70.5% vs 76.3%). AR incidence under ESW was higher at 6 months (13.6% vs 8.7%) and 1 year (17.6% vs 11.8%) post-transplant. All-cause graft failure was uncommon (4% vs 4.6% at 1 year). Using multivariable logistic regression (Table 2), ESW was associated with 62% higher odds of AR at 6 months (CI:1.00-2.63, p=0.048) and 57% higher odds at 1 year (CI:1.03-2.40, p=0.04). Older donor and younger recipient ages, and recipient black race were associated with increased odds of AR at 1 year.

*Conclusions: In the first year post-HIV+ KT, ESW was associated with 62% increased odds of AR (absolute increase 5.8%). ESW should be weighed on an individual basis, balancing AR risk versus steroid complications.

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