Roughly 15% of kidney transplant recipients on a rapid discontinuation of prednisone (RDP) protocol have > or =1 episode of acute rejection (AR). One clinically important question is whether long-term maintenance steroids should be introduced in those recipients having AR. Of 842 adult kidney transplant recipients on an RDP protocol, 149 (17.7%) have had at least 1 AR episode. Of these, 51 (34%) started on maintenance prednisone (5 mg/day) after treatment of the AR, while 98 (66%) remained steroid free. Demographics for the two groups were similar. With mean follow-up of 26 months, 48 (32%) of the recipients have had a 2nd AR episode: 15 (29.4%) in those on maintenance steroids vs. 33 (33.7%) in those remaining steroid free (p = 0.12). Graft survival was not significantly different between the two groups. Multivariate analysis of risk factors for a 2nd episode found the histologic appearance of the initial AR episode to be the most significant risk factor. But, whether steroids were added to the maintenance regimen or not, also seemed to have an impact (RR = 2.1, p = 0.07). At present there is evidence to suggest that some SA patients should start on maintenance steroids after AR. However, longer follow-up with more patients is necessary.