*Purpose: The purpose of this study is to evaluate rejection outcomes in those requiring renal replacement therapy (RRT) after liver transplant.

*Methods: This was a single center, retrospective, cohort study evaluating rejection in patients requiring RRT (n=86) vs. no RRT (n=158) that were transplanted between January 2017 and August 2019. The primary outcome was the incidence of biopsy proven acute rejection (BPAR) within 12-months. Secondary outcomes include patient and graft survival, infection, renal dysfunction, and immunosuppression practices within 12-months.

*Results: Differences in baseline characteristics (table 1) were not associated with increased rejection or mortality in a multivariable analysis. Median tacrolimus troughs were higher in the no RRT group at all time points except at 12-months (P=0.065). BPAR at 12-months post-transplant was significantly higher amongst those requiring RRT (36% vs. 13%, P<0.001). All rejections were mild to moderate in severity, with more treated rejections in the RRT group (13% vs. 4%, P=0.008). Patient survival at 12-months was 77% for those receiving RRT and 94% for those not requiring RRT (P<0.001) (table 2). Infection (HR 3.8, 95% CI 1.6-8.8; P<0.001), but not rejection (HR 0.7, 95% CI 0.3-1.7; P=0.5) was an independent predictor of mortality (table 3).

*Conclusions: Although the incidence of rejection was higher in those requiring RRT, our study suggests that permissive rejection may be an acceptable strategy in patients receiving RRT following liver transplant to balance the detrimental impact of infection on mortality.

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