*Purpose: Although there is a tendency to treat late clinical TCMR, the responsiveness to steroids is unclear.

*Methods: Among kidney transplant recipients, transplanted between Jan 2013 and December 2017, we followed clinical rejections (beyond 6months) in a cohort of patients who had undergone a 3 month surveillance biopsy and no episodes of clinical rejection. Of the 62 patients who had a late rejection, 45 had pure TCMR (Banff IA/IB in severity). The majority of the patients (>95%) were induced with thymoglobulin at the time of transplant. Those who were diagnosed to have TCMR were treated with steroids 250 mg iv for a total of 3 doses. We compared baseline GFR, GFR at time of biopsy and the best GFR within 3 months of rejection treatment in the TCMR group. Based on the GFR response, the patients were divided into those that continued to have worsening GFR post treatment (n=12) and those where GFR stabilized or improved post treatment (n=33). Based on the binary variable of response to treatment, a multivariable logistic regression was performed taking into consideration recipient age, sex, race, sensitization, DGF and DSA. We used the total i score to account for inflammation in the scarred areas.

*Results: The median change in GFR among all clinical TCMR was 4 ml/min (IQR -0.5 to 7.8). Multivariable analysis revealed IFTA score>2 (p=0.017; OR 7.6, CI 1.4-40) was associated with lack of improvement post treatment.

*Conclusions: 1. Therapeutic response of pure late T cell mediated rejection to steroids is modest at best, with a median change in GFR of only 4 ml/min. 2. IFTA score of greater than 2 was associated with a poor therapeutic response in pure TCMR. 3. Factors impacting response to late TCMR should be analyzed in larger studies given poor responsiveness to treatment.

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