Background: Calcineurin inhibitors are frequently delayed to allow for recovery of renal function after transplantation; however, there is a paucity of literature supporting a delay beyond 7 days in liver transplant recipients who have received induction with an IL-2 receptor antagonist. The purpose of this study is to compare acute rejection prevalence, graft outcomes, and renal function between patients receiving early and delayed tacrolimus initiation up to post-operative day (POD) 14. Methods: This is a retrospective, single center cohort study of adult liver transplants from November 2012 to November 2013 who received basiliximab induction. Exclusion criteria included previous and multi-organ transplants. Patients were stratified by those with early initiation (EI, POD 1-4) or delayed initiation (DI, POD 5-14) of tacrolimus. One-year biopsy-proven acute rejection (BPAR) rate, renal function, death censored graft survival, and mortality were reported. Statistical analyses were performed with Fisher's exact test and paired and unpaired t-test with p<0.05 considered significant. Results: 61 patients were stratified into the EI (n=43) and DI cohorts (n=18). Baseline characteristics were similar between groups, including MELD score (EI: 19.7 v. DI: 20.1, p=ns) and eGFR prior to transplantation (EI: 66.7 v. DI: 67.8 mL/min/1.73m², p=ns). Significantly more patients in the DI group received renal replacement therapy during the transplant admission vs. the EI group (4.7 v. 44.4%, p= 0.0005). Death censored graft survival was similar between groups (90.7 v. 88.9%, p=ns), as was patient survival (86.0 v. 83.3%, p=ns). In the EI group, 7 patients (16.3%) had at least 1 BPAR episode, while the DI group had 2 patients (11.1%) with BPAR (p=ns). The 2 BPAR events in the DI group occurred within 30 days of transplantation, while all BPAR events in the EI group occurred beyond 30 days of transplantation. There is no significant difference in one year eGFR from baseline in the EI and DI groups (EI: 66.7 v. 67.2, DI: 67.8 v. 51.6 mL/min/1.73m²; p=ns). Conclusions: Basiliximab induction in liver transplantation allows for the safe delay of tacrolimus therapy up to 14 days post-transplant in order to facilitate renal function recovery.

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