*Purpose: In the USA, there was a 51.1% reduction in kidney transplant (KTx) since March 2020 due to concerns for contraction of COVID-19 in transplant recipients. In our center, cumulative doses of ATG induction were reduced from 4-6mg/kg to 2-4 mg/kg in immunological high risk [HR] [age < 55 years, AA, cPRA > 20%, 2 DR mismatch, KP, retransplant], from ATG 2-4 mg/kg to 1-2 mg/kg in moderate-risk [MR] [age > 55 years, non-AA, CPRA <20% and <2 DR mismatch) and from ATG 0-2mg/kg to basiliximab for low risk [LR] patients [LDKT, age >65 years, cPRA < 20%, with 0 to 1 DR mismatch]. We used Tacrolimus and Myfortic as a maintenance agent and continued with a five-day rapid steroid withdrawal. This study assessed the effect of these changes on our transplant outcomes.

*Methods: We conducted a retrospective chart review of all adults with KTx or KP from 3/1/2020 to 8/31/2020 with a follow-up of at least two months. Primary outcomes included the incidence of biopsy-proven rejection (BPAR), de-novo DSA, delayed graft function (DGF), infection rate, graft loss, and all causes of mortality.

*Results: 180 KTx and 5 KP were reviewed with a median follow-up of 161 days [66, 250]. 13% were LDKT, and 11% retransplant. Median recipient age was 55 years [21, 78], and 28% were > 65 years old. 64% were white, and 63% were male. 46% of organs were PHS high-risk, median KDPI was 49 [2, 96], CIT 12 hours (2, 47). Median donor creatinine was 1.3mg/dL (0.2, 7.15). 62% HR received ATG of 3-4mg/kg, 8% MR received 1-2mg/kg, and 30% LR received basiliximab. Creatinine nadir was 1.35mg/dL (0.52, 3.57). DGF was similar to the national average at 23%. 5% developed new DSA [MFI>2000]. Three patients had Banff 1a rejection. Patient 1 received basiliximab (LR) but likely rejected due to IS reduction during his COVID illness. Patients 2 and 3 both received ATG [HR] and were treated with increased IS and steroids. All three responded well to treatment. Three patients were diagnosed with COVID-19 and responded well to remdesivir, dexamethasone, and convalescent plasma. The median time of diagnosis from transplant was 90 days [12, 210], and the recent creatinine was 1.5mg/dL [1.2, 2.42]. 19% of CMV PCR (+) required dose reductions of IS, while 30% required CMV treatment. BK PCR of >10,000 was noted in 5.4% patients. Two graft losses occurred within a week of transplant secondary to the renal vein thrombosis. No mortality was noted.

*Conclusions: With careful monitoring and reduction in induction immunosuppression, KT and KP transplants could be performed safely during the COVID pandemic.

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