*Purpose: Failed kidney allograft is the fourth leading indication for kidney transplantation. A significant portion of second kidney transplant recipients undergo preemptive transplantation while on maintenance immunosuppression. We examined the association between the type of induction used and long-term graft and recipient survival.

*Methods: Using the SRTR, we identified all preemptive second kidney transplant recipients. We excluded those with missing or unusual induction regimens, recipients with maintenance other than tacrolimus and Mycophenolate +/- steroids and those with crossmatch positive results. We grouped recipients by induction type into four groups: Anti-thymocyte globulin group (n=1335), Alemtuzumab group (n=332), IL-2 Receptor Antagonist group (n=477) and No-induction group (n=165). We generated Kaplan-Meier curves of recipient survival (RS) and death-censored graft survival (DCGS) with follow up censored at ten-year post-transplant. We used Cox proportional hazards models to examine the effect of induction along with other factors on the outcomes of interest. To account for center specific effect, we included center as a random effect. We adjusted for recipient age, gender, race, diabetes, PVD, ESRD etiology, donor type and gender, HLA-MM, steroid maintenance, time between transplants, payor type and transplant year. The (RS) model was stratified by donor gender and HLA-Mismatch, whereas the (DCGS) model was stratified by donor type due to proportional hazards violations.

*Results: Glomerulonephritis was the leading cause of ESRD among the groups accounting for over 40% of the recipients. Rates of DGF, rejection, hospitalization, and PTLD at one year were not statistically different. Mean creatinine was slightly higher in the no-induction group. In the Kaplan-Meier analyses, neither (RS) (log-rank p=0.729) nor (DCGS) (log-rank p=0.077) (Figure 1) differed by induction type. In the fully adjusted models, induction type was not a predictor of recipient or graft survival. Live-donor kidney was a favorable predictor of (RS) [aHR 0.66, 95% C.I. (0.50, 0.86), p=0.002]. Publicly insured recipients had worse recipient and allograft survival outcomes.

*Conclusions: In this large cohort of crossmatch negative second pre-emptive kidney transplant recipients who were discharged on tacrolimus and mycophenolate maintenance, induction type was not associated with improved rejection rates, recipient or graft survival. Live-donor kidneys improved recipient survival.

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