*Purpose: Currently there is no consensus among pediatric kidney transplant centers regarding the use and regimen for immunosuppressive induction therapy.The safety and effectiveness of reduced Rabbit Antithymocyte Globulin (ATG) ≤ 3.5 mg/kg cumulative dosing as induction therapy in low risk pediatric kidney transplant recipients is unknown.

*Methods: Pediatric renal transplant recipients transplanted 1/1/2013-5/1/2018 were considered for inclusion. Recipients of deceased or living donor organs and with least 12-month follow-up were included. “High risk”was defined by a repeat transplant, preformed donor specific antibodies (DSAs), peak panel-reactive antibodies >20%, or African-American race. Maintenance immunosuppression protocol was tacrolimus and mycophenolate mofetil, steroid free unless high risk. Outcomes were de novo DSA (dnDSA) formation, graft survival , biopsy proved rejection (BPR) and EBV/CMV/BK viremia/infection during the first 12 months. DSAs were routinely screened at 3,6 and 12 months. Protocol biopsies were done at 6 and 12 months and graded with Banff criteria. Additional DSA testing and/or biopsies were done if there was a clinical concern. Subclinical/borderline findings were included with or without treatment. Group 1: low risk patients, ATG dose of ≤ 3.5 mg/kg, Group 2: low risk patients receiving dose of >3.5 mg/kg and Group 3: high risk patients.

*Results: Results: A total of 181 patients met inclusion criteria. Age of patients was 11 years (11 mo-21 y),(median, range), 21% received a living donor transplant and 49% were female. Graft survival and dnDSA formation did not differ significantly between the three treatment groups. Graft loss at 12 months was a rare event with 99.5% graft survival and patient survival was 100%. Patients outcomes based on groups is shown below.

*Conclusions: Reduced ATG dosing (≤ 3.5 mg/kg) when compared with higher dosing (>3.5 mg/kg) is safe and effective. Reduced ATG dose was associated with lower rates of BK viremia and BK nephropathy without increasing risk of dnDSA or BPR.

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