*Purpose: Early SW (<7 days posttransplant) has been associated with minimization of steroid-related side effects and improved cardiovascular risk profile. Yet, in the U.S., only ~30% new kidney tx recipients are treated with early SW due to concern about increased acute rejection rates and long-term outcomes.

*Methods: To assess long-term outcomes, 1123 kidney recipients (762 LD; 361 DD) undergoing early SW between 1999 and 2009 at a single center were matched (see Table) using sparse, optimal matching with refined covariate balance constraints – using SRTR data – to recipients at large volume centers receiving maintenance prednisone at hospital discharge (5:1 matching ratio). Graft (GS) and patient (PS) survival were estimated by donor type and steroid group using Kaplan-Meier (KM) estimators, and compared between groups using log-rank tests. Due to small residual imbalances among covariates after matching, we estimated the hazard ratio (HR) of maintenance prednisone vs SW using proportional hazards models adjusting for common recipient, donor, and surgical characteristics.

*Results: Median (IQR) followup was 10.3 (5.4 – 13.4) and 7.6 (3.8 – 11.6) years for LD and DD, respectively. By KM, compared to maintenance prednisone, DD receiving SW had significantly better PS throughout 20-yr f/u (adjusted HR, 1.46; 95% CI, 1.18-1.80) (Figure). There was no difference in DD GS, or in LD PS or GS; and no evidence of increased long-term (>10 years) graft failure associated with early SW.

*Conclusions: We conclude that early SW has similar or better long-term outcomes than maintenance prednisone.

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