*Purpose: Renal dysfunction after liver transplantation (LT) is associated with increased morbidity and mortality. Early exposure to calcineurin inhibitors (CNI) is a risk factor for renal dysfunction after LT. Attempts to delay CNI introduction with the addition of induction immunosuppression (IS) in LT candidates with renal dysfunction have shown mixed results. Here, we report our experience with induction strategies versus no induction in the setting of delayed CNI initiation on renal function after LT.

*Methods: Between January 2016 and June 2021, we retrospectively reviewed outcomes of adult primary liver only transplant recipients (LTR) with renal impairment. Renal impairment was defined as the need for dialysis or SCr greater than or equal to 1.8 mg/dL at the time of LT or within 24-hours after LT. Patients meeting criteria received either induction with rabbit anti-thymocyte globulin (rATG) or basiliximab (Group 1) or no induction (Group 2). All patients received perioperative steroids and delayed CNI initiation. The primary outcome was the change in estimated glomerular filtration rate (eGFR) from baseline to 3-months post-LT.

*Results: A total of 79 LTR were included (38 in Group 1 and 41 in Group 2). Patients in Group 2 had a higher median MELD-Na score compared to those in Group 1, 40 vs. 29 (p < .001), were more likely to be on dialysis prior to transplant, 71% vs. 24% (p < .001), and had a lower mean baseline eGFR, 18.2 ± 8 mL/min/1.73m² vs. 41.0 ± 30 mL/min/1.73m² (p < .001), respectively. At 3 months, patients in Group 2 had a significant improvement in mean eGFR, 28.6 ± 27 mL/min/1.73m², compared to those in Group 1, 8.8 ± 37 mL/min/1.73m², (p = 0.007). BPAR rates within the first 30-days were 15% vs. 0% (p = 0.03), respectively, and 4/6 (67%) were mild. One-year post-LT, there was no difference in graft survival (100%), patient survival (97-100%), or the incidence of opportunistic infections.

*Conclusions: Our cohort that received no induction with delayed CNI initiation had a significantly greater improvement in eGFR at three months post-transplant compared to the induction group despite having a higher MELD-Na score and worse baseline eGFR. Although BPAR was higher in the no induction group, one year patient and graft survival were not statistically different. Herein, we report that delayed CNI initiation without induction IS in LTR with renal impairment is safe and could result in significant cost savings.

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