*Purpose: Acute rejection after liver transplant is associated with increased risk of graft failure and mortality. Reports on rejection rates in living donor liver transplants (LDLT) rarely delineate patients who received rabbit antithymocyte globulin (rATG) as induction therapy. This study analyzes outcomes in LDLT recipients with regard to induction and maintenance immunosuppression received.

*Methods: This single-center, retrospective cohort analysis included LDLT transplanted 01/2012 to 08/2020. Patients who died within 7 days or were re-transplanted within 30 days of LDLT were excluded. A protocol change in 2019 eliminated the use of rATG induction, delayed calcineurin inhibitor (CNI) initiation, and extended the corticosteroid taper for all liver transplant patients. All patients were started on mycophenolate mofetil 1000 mg twice daily or equivalent. Rejection was defined as biopsy-proven or clinically diagnosed based on lab values. Infection was assessed at 3 and 6 months by provider notes, medications, and lab results.

*Results: Baseline characteristics and outcomes are shown in Table 1. rATG induction was given to 47 LDLT recipients, and 50 received no antibody induction. No significant differences in demographics were noted aside from a trend toward higher MELD-Na score in the rATG group. CNI initiation was significantly earlier in the rATG group. No significant differences were noted in rejection, graft survival, patient survival, renal function, infections, or readmissions between the two groups. Time to rejection, patient survival, and graft survival showed no differences.

*Conclusions: In LDLT recipients, there was no noted benefit or harm in the use of rATG induction with regard to rejection, infection, renal function at 3 months, or 1 year patient or graft survival. Outcomes were overall similar compared with no antibody induction and empiric CNI delay to 1 to 3 days post-LDLT. No induction may be considered in living donor liver transplant and provides a cost savings opportunity.

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