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Background & Aims Low calcineurin inhibitor (CNI) levels expose liver transplant recipients to rejection episodes and potentially to antibody‐mediated rejection. There are little data on the impact of CNI‐free immunosuppression on de novo donor‐specific HLA antibody (dnDSA) development. Here we evaluated the prevalence of dnDSA in liver transplant recipients on CNI‐free maintenance regimens and their associations with histopathological abnormalities of allografts. Methods Seven hundred and twenty‐seven liver transplant recipients underwent a first liver transplant between 2000 and 2018 in three French transplant centres and had protocolized follow‐up with dnDSA screening and allograft biopsy 1, 5 and 10 years after transplantation. Results CNIs were withdrawn in 166 (22.8%) patients with or without conversion to mammalian target of rapamycin inhibitors and/or maintenance with mycophenolic acid. DSA were present after withdrawal in 30.1% (50/166) patients on CNI‐free immunosuppression compared with 16% (90/561) on CNI maintenance therapy (p < 0.001). The cumulative incidence of dnDSA 10 years after transplant was 20% in the CNI group versus 28% in the CNI‐free group (p < 0.01). dnDSAs were associated with histological graft abnormalities (significant allograft fibrosis or rejection) (HR 2.24, 95% CI 1.2–4.1; p = 0.01). In univariate Cox regression analysis, being on a CNI‐free regimen did not impact graft histology. Conclusions Patients on a CNI‐free IS regimen have a higher prevalence of dnDSA than patients on a standard IS regimen. dnDSAs but not CNI‐free immunosuppression were associated with abnormal allograft histology.

included were otherwise given the hospital's standard discharge summary. Follow-up compliance rates for keeping appointments were compared over the 1-year periods before and after the implementation.Of the 100 consults included, 57.0% were women with a mean age of 63.3 (standard deviation, 19.7) years. In line with previous studies, 2,3 our consultations had a significant impact on the inpatient management of skin conditions, changing the diagnosis and treatment plan in 69% and 83% of cases, respectively (Table I). Multivariate regression analysis showed that patients given the dermatologyspecific discharge form were more likely to follow-up compared with consult patients before this implementation (60.4% vs 21.2%; risk ratio, 2.25; 95% confidence interval, 1.18-4.28; P ¼ .004). Patients with an acute flare of a chronic condition (compared with an acute new condition) were also more likely to follow-up (risk ratio, 2.11; P ¼ .003), whereas there was no statistically significant difference in follow-up rates based on age or sex (Table II).Improved outpatient follow-up compliance rates with use of a dermatology-specific discharge form may be due to improved accuracy and specificity of dermatology information provided to patients upon discharge. One possible contributing factor is that the form is designed to be completed by the consulting dermatologist, as one study found that the accuracy rate of dermatology documentation in hospital discharge summaries completed by nondermatologists was only 54.5%. 4 The study is limited by its retrospective nature and generalizability given the implementation at a single community-based academic medical center. Although patients in the intervention group had reduced all-cause 30-day hospital readmission rates (6.9% vs 9.2%, P ¼ .03), it is beyond the scope of this study to correlate this with the higher rates of clinic follow-up. Future studies evaluating use of a dermatology-specific discharge form as a mechanism for reducing readmission rates of inflammatory skin conditions are warranted.