Early episodes of acute rejection (AR) are known to have deleterious effects in the graft outcome. Incidence of AR in the first three months is reported to be less than 20%. An audit of AR episodes was conducted in our unit recently since we found our rates to be on the higher side (30%). Consecutive cases of 100 renal transplants done in our unit over a period of 18 months were selected for the audit. Details of type of donor, induction therapy, immunosupprerssion (IS) medications, drug levels, HLA mismatches, episodes of acute tubular necrosis (ATN) and delayed graft function (DGF), AR episodes and it’s response to therapy were all retrospectively collected from the hospital records. The AR rates were correlated with IS protocols, drug levels, HLA mismatches, DGF and type of donor. 30 rejection episodes occurred after a mean period of 14.3 (6-47) days after transplantation. 91 patients had induction treatment with either antithymocyte globulin (ATG) or interleukin 2 receptor antibodies (IL2 Rab). IS drugs used included cyclosporin, mycophenolate, sirolimus, azathioprine and prednisolone in these patients. There was no significant difference in AR episodes amongst different IS protocols (30.7 – 35.2%). Subjects with 4 or more HLA mismatches had higher episode of AR (40.3%) compared to those with 3 or less (23%). Subjects with ATN or DGF immediate post transplant had a higher incidence of AR (39.2%) than those who did not have them (26.3%). Cadaver donor recipients had a higher episode of AR (45.1%) compared to live related donor recipients (25%). On stratifying the known risk factors for AR, it was found that subjects with no risk factors had the least (22.2%) episodes of AR compared to those with a single (32.5%) or double (47.6%) risk factor. Subjects who failed to achieve adequate cyclosporin (C2) levels had significantly high rates of AR (86.9%) compared to those with adequate or higher levels (8.6%). Higher HLA mismatches, DGF, cadaver donor and failure to achieve adequate cyclosporin levels were found to be the major risk factors for the development of AR in this audit. a rapid increase in blood viscosity as a result of excellent early graft function might be responsible for PTDM.