The incidence of ABO-incompatible (ABO-i) kidney transplantation (KT) is increasing; however, it has been reported to have higher early mortality rates compared to ABO-compatible (ABO-c) KT. This is largely attributed to extensive use of immunosuppressive agents. While efforts to reduce steroid use are common in ABO-c KT, they are less prevalent in ABO-i. Therefore, our study aims to investigate the specific impact of steroid withdrawal on graft survival in ABO-i KT patients. This retrospective observational study included all patients who underwent ABO-i KT at Wonju Severance Christian Hospital from January 2014 to December 2021, with a total of 33 patients included. The primary outcome was biopsy-proven acute cellular rejection. Secondary outcomes included graft function, infection, new-onset diabetes mellitus after transplantation (NODAT), and delayed graft function. Over an average follow-up period of 57.0 ± 23.7 months, the cumulative probabilities of rejection at 3 years post-transplantation were 30.8% in the steroid maintain group and 40.0% in the steroid withdrawal group, with no significant difference (p = 0.648, HR 1.113 95% CI 0.315-3.925). (Figure 1A) Steroid withdrawal did not affect the rates infection, NODAT, osteoporosis, CVD and BKV viremia, CMV viremia. (Figure 1) During the follow-up period, eGFR was compared between the steroid maintain group and the steroid withdrawal group. At 1 year, the eGFR was 65.5 ± 31.4 in the steroid maintain group and 67.2 ± 14.7 in the steroid withdrawal group (p = 0.829). At 3 years, the eGFR was 53.2 ± 25.1 in the steroid maintain group and 61.8 ± 19.7 in the steroid withdrawal group (p = 0.316), showing no statistically significant differences between the two groups. (Figure 2). Compared to steroid maintenance, steroid withdrawal did not affect rejection or graft function due to any cause.