*Purpose: Pre-transplant blood transfusion is a well-established risk factor for sensitization to human leukocyte antigens (HLA). HLA sensitization is associated with increased wait-list time, risk for antibody mediated rejection (ABMR), and reduced graft survival. While a strong consensus exits regarding the need to avoid pre-transplant blood products transfusion, perioperative blood transfusion remains a very common practice. The effect of such practice on post-transplant sensitization, development of de novo donor specific antibodies (DSA), and acute rejection has not been well evaluated.

*Methods: We performed a retrospective analysis of all non-sensitized patients who received a kidney transplant at our center between July 1^st of 2015 and July 31^st of 2017. Patients who received any blood transfusion between post-operative day 0 and day 45 were considered the transfusion group. Patients who did not receive blood products during this period were considered the control group.

*Results: A total of 236 patients were included with 114 (48%) patients in the transfusion group and 122 (52%) in the control group. Patients in the transfusion group were older (54.2±12 vs 50.5 ±13.1, P= 0.029), received more kidneys from deceased donors (68.4% vs 45.9%, P=0.0002), and were less likely to be discharged on calcineurin inhibitors (CNI) based regimen (81.3% vs 91.8%, P= 0.005). There was no difference in the prevalence of DSA at 3 months (2.5% vs 1.8%, P>0.999) and 12 months (13.1% vs 14%, P >0.999) between the two groups. Acute rejection within the first year was significantly higher (20.2% vs 3.3%, P<0.0001) and time to first rejection was significantly shorter (112.0 ± 184.8 days Vs 382.3 ± 295.2 days, P=0.001) in the transfusion group. Rejection episodes were primarily cellular (32/35). In subgroup analysis of patients discharged on CNI, acute rejection remained significantly higher in the transfusion group (14% vs 2%, P= 0.0004). Cox multivariate proportional hazards modeling indicated that CNI free regimens and transfusion were significantly associated with shorter time to rejection. When adjusting for immunosuppressive therapy, transfusion remained a significant risk factor for time to rejection (HR 5.677, CI: 1.94-16.58, P= 0.0015).

*Conclusions: Early post-transplant blood transfusion is associated with increased risk for rejection. Increased awareness of this risk and calls for more conservative anemia management similar to that practiced in the pre-transplant setting is needed.

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